!C99Shell v. 1.0 pre-release build #13!

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Viewing file:     Claim Incident Report.htm (13.36 KB)      -rw-r--r--
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Claim Incident Report
 

Claim Incident Report

ALLSTATE AGENT INFORMATION  
Name of Allstate Agent
Contact
Email Address
Telephone Number
Fax Number
INSURED INFORMATION  
Insured Name
DBA
Street Address
City or Town
State
ZIP Code
Contact
Telephone Number
Email Address
Fax Number
INCIDENT INFORMATION  
Date of Occurrence
Insured Policy
Location of Occurrence
Description of Occurrence
CLAIMANT INFORMATION  
Name of Claimant
Contact
Claimant Address
Claimant Phone
Claimant Email
Claimant Fax
Injury or Property Damage

Clicking on the Submit button will send your completed form to Butwin Insurance. 
To print a copy of this form, click here prior to submitting the form.
 

    

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