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New Assignment for Charles Taylor Adjusting
Your Contact Information
First Name
Last Name
Company
Address (Line 1)
(Line 2)
City
State	AAABAEAKALAPARAZBCCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMBMDMEMIMNMOMSMTNBNCNDNENFNHNJNMNSNUNVNYOHOKONORPAPEPRQCRISCSDSKTNTXUTVAVTWAWIWVWYYT
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eMail:
New Assignment Information
Your Claim #:
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:	OtherCollapseFireHailIce DamLiabilityLightningMoldSewageSewer BackupSlip & FallTheftTornadoVandalismVehicle Caused Damage - PropertyWaterWindSmokeSnow/Ice EarthquakeFloodFreezeHurricaneLegalAppraisalDesk ReviewExpert EvaluationStorm DamageAccidental DamageEscape of WaterBurst PipeAuto CollisionPIPElectrical FireConstruction DefectHeavy EquipmentInland MarineCargoAutoCommercial AutoDirect Repair Programs - Property/Auto3rd Party LiabilityWind/HailWater HeaterPlumbing Leak
Unit:	Residential ClaimsCommercial ClaimsLarge LossLiability ClaimsFarm-RanchDesk AdjusterNO Liability ClaimsNO Commercial ClaimsPropertyAutoBuisnessMulti-Dwelling
Type of Adjustment:	Limited Full
Loss Description: Characters left:
VIN #:
Deductible:
Wind Deductible:
Coverage ABuildingBusiness Personal PropertyDwellingPersonal PropertyLiabilityGross LossAdjuster FeesExpenses
Coverage BBuildingBusiness Personal PropertyDwellingPersonal PropertyLiabilityGross LossAdjuster FeesExpenses
Coverage CBuildingBusiness Personal PropertyDwellingPersonal PropertyLiabilityGross LossAdjuster FeesExpenses
Coverage DBuildingBusiness Personal PropertyDwellingPersonal PropertyLiabilityGross LossAdjuster FeesExpenses
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