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Policy Number:
Company Name:
Contact Person:
Whom should the adjuster call to settle your claim?
Name:
Home Phone:
Work Phone:
e-Mail:
Best time to call:
Authority Contacted:
Police/Fire dept:
Report number:
Claim Information:
Date of loss:
Location of claim:
Cause of loss:
Describe Your Damages/Loss:
Emergency services needed: Temporary Shelter Required? Yes  No
Windows Required Board up? Yes  No
Other?:                  
Persons Injured:
Name/address
Phone number:
Nature of injuries:
Cause of injuries:
Comments and/or Other Information:

Please Note: Insurance coverage cannot be bound without a written binder from our office.

 

Robert Wehn and Associates 2859 83rd Ct,. Darien, IL
Phone: (630) 910-9600 Fax: (630) 910-9601
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