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Insurance details

Claim / reference number

Date of loss

Type of loss

Fire

Structural

Environmental

Water damage

Other…

Other type of loss

Insured

Insured's contact

If different from the insured.

Name

Company

Email

Phone

Address

Address 2

City/Town

State/Province

Postal Code

Insured's phone

Extension

Location of loss

Address

Address 2

City/Town

Province

ZIP/Postal Code

Litigation details

Your reference number

Your client in the matter

Your client's reference number

Plaintiff

Defendant

We are acting on behalf of

Plaintiff

Defendant

Other…

Other party's role

Incident location

Address

Address 2

City/Town

State/Province

Postal Code

Assignment details

PO / Reference Number

Job location

Same as billing address

Other address

Job address

Address

Address 2

City/Town

Province

Postal Code