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  ASSIGNMENT SHEET -   * indicates a Required Field  
             
  Claims Rep:   Claim No.:  
             
  Company:   CR Phone Cell:  
             
  Address:   Fax:  
             
  City:   *E-mail: An email value is required
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  State:   Attorney:  
             
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  INSURED INFORMATION -        
             
  Insured:   Address:  
             
  Phone No.:   City:  
             
  State:   Zip:  
             
     
  STRUCTURE LOSS INFORMATION -  
     
  Loss Location:  
             
  Date of Loss:   Type of Building:  
             
  Time of Loss:   Occupants:  
             
  Coverage:        
             
  Comments:  
             
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  VEHICLE LOSS INFORMATION -        
             
  Date of Loss:   Time of Loss:  
             
  Vehicle License No.:   Lot No.:  
             
  VIN No.:   Called Tow Yard:
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  Location Phone No.:   Permission to View:
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  CurrentĀ Location
of Vehicle:
 
             
  Special Instructions:  
 
 
 
On submission, if you are not re-directed to a "THANK YOU" page in a few seconds, please check that you filled out the email field correctly.
 
 
             
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