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New Assignment for Hausch & Company
Your Contact Information
First Name
Last Name
Company
Address (Line 1)
(Line 2)
City
State	AAABAEAKALAPARAZBCCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMBMDMEMIMNMOMSMTNBNCNDNENFNHNJNMNSNUNVNYOHOKONORPAPEPRQCRISCSDSKTNTXUTVAVTWAWIWVWYYT
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New Assignment Information
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Assignment Instructions: Characters left:
Insured's Information
Policy #:
Phone #:
Alternate Phone #:
Company:
First Name:
Last Name:
Street Address:
Address 2:
City:
State:	AAABAEAKALAPARAZBCCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMBMDMEMIMNMOMSMTNBNCNDNENFNHNJNMNSNUNVNYOHOKONORPAPEPRQCRISCSDSKTNTXUTVAVTWAWIWVWYYT
Zip:
Mortgagee:
Loss Location
Street Address:
Address 2:
City:
State:	AAABAEAKALAPARAZBCCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMBMDMEMIMNMOMSMTNBNCNDNENFNHNJNMNSNUNVNYOHOKONORPAPEPRQCRISCSDSKTNTXUTVAVTWAWIWVWYYT
Zip:
Claimant Information (if applicable)
First Name:
Last Name:
Phone:
Street Address:
Address 2:
City:
State:	AAABAEAKALAPARAZBCCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMBMDMEMIMNMOMSMTNBNCNDNENFNHNJNMNSNUNVNYOHOKONORPAPEPRQCRISCSDSKTNTXUTVAVTWAWIWVWYYT
Zip:
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First Name:
Last Name:
Company:
Office Phone:
Cell Phone:
Street Address:
Address 2:
City:
State:	AAABAEAKALAPARAZBCCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMBMDMEMIMNMOMSMTNBNCNDNENFNHNJNMNSNUNVNYOHOKONORPAPEPRQCRISCSDSKTNTXUTVAVTWAWIWVWYYT
Zip:
Country:
Loss Information
Date of Loss:
Type of Loss:	OtherCargoCollisionFireFloodHailTornadoWindWind/RainBurglaryTheftVandalism & Malicious MischiefFreezeExplosionLightningSewer/Water Back-UpWork AccidentSlip and FallCollisionProduct LiabilityCasualtyPhysical DamageHeavy Equipment DamageLiabilityProperty DamagePotholeTornadoWater DamageFood SpoilagePower SurgeGAPVSIMechanical Breakdown ExpenseSkipE&OEarthquakeSettling- Structural FailureVehicle hit structureFreezeTax & DemoBodily InjuryPower OutageProperty Damage - LiabilityMoldEquipment BreakdownLoss of RentBusiness InterruptionRiot/Civil CommotionEvacuation ExpenseConstruction DefectCollapseSinkhole CollapseBreach of ContractCollapse - SnowAppraisal DemandLoss of personal propertyImpound ExpenseDeductible ReimbursementInland MarineWear and TearTax and DemoWind/Hail
Unit:	Residential PropertyCommercial PropertyPersonal AutoCommercial AutoCargoWorkman's CompensationHeavy Equipment AppraisalAuto AppraisalLiabilityResidential - CATCommercial - CAT
Type of Adjustment:	Limited Full
Loss Description: Characters left:
VIN #:
Deductible:
Wind Deductible:
Coverage AGreat American Tenant Liability ClaimsGreat American BCPIIndemnityBank ChargesAdjusters FeesTPA FeesExpensesAttorney Coverage FeesDefense Fees1st Party-Paying Insured3rd Party-Liability Paying ClaimantPersonal PropertyProperty DamagePhysical DamageCULL - Liability ClaimCollision Loss AutoStructureBusiness InterruptionBusiness Personal PropertyDebris Removal - Additional Coverage Comprehensive Loss AutoH&C-Adjusting FeesOther IA's-3rd PartyH&C-TPA FeesExpert FeesDwellingRecovery General ExpenseRecovery General IndemnityBreach of Contract
Coverage BGreat American Tenant Liability ClaimsGreat American BCPIIndemnityBank ChargesAdjusters FeesTPA FeesExpensesAttorney Coverage FeesDefense Fees1st Party-Paying Insured3rd Party-Liability Paying ClaimantPersonal PropertyProperty DamagePhysical DamageCULL - Liability ClaimCollision Loss AutoStructureBusiness InterruptionBusiness Personal PropertyDebris Removal - Additional Coverage Comprehensive Loss AutoH&C-Adjusting FeesOther IA's-3rd PartyH&C-TPA FeesExpert FeesDwellingRecovery General ExpenseRecovery General IndemnityBreach of Contract
Coverage CGreat American Tenant Liability ClaimsGreat American BCPIIndemnityBank ChargesAdjusters FeesTPA FeesExpensesAttorney Coverage FeesDefense Fees1st Party-Paying Insured3rd Party-Liability Paying ClaimantPersonal PropertyProperty DamagePhysical DamageCULL - Liability ClaimCollision Loss AutoStructureBusiness InterruptionBusiness Personal PropertyDebris Removal - Additional Coverage Comprehensive Loss AutoH&C-Adjusting FeesOther IA's-3rd PartyH&C-TPA FeesExpert FeesDwellingRecovery General ExpenseRecovery General IndemnityBreach of Contract
Coverage DGreat American Tenant Liability ClaimsGreat American BCPIIndemnityBank ChargesAdjusters FeesTPA FeesExpensesAttorney Coverage FeesDefense Fees1st Party-Paying Insured3rd Party-Liability Paying ClaimantPersonal PropertyProperty DamagePhysical DamageCULL - Liability ClaimCollision Loss AutoStructureBusiness InterruptionBusiness Personal PropertyDebris Removal - Additional Coverage Comprehensive Loss AutoH&C-Adjusting FeesOther IA's-3rd PartyH&C-TPA FeesExpert FeesDwellingRecovery General ExpenseRecovery General IndemnityBreach of Contract
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