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Please fill out the following form to report a new assignment.
If you have any questions, please call us at 770.552.7220.



claim information
claim or reference number
date of loss
loss location
type of assignment

client information

your name
e.mail address
company
phone
fax

contact information

contact
phone

policy information

description & terms
limits
monthly limit (if applicable)
coinsurance percentage (if applicable)
policy period to.
specific instructions &
other comments

 

  
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