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McCloud Claims Service Inc.

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* Company Name:

*Company Address:

*Phone:

Fax:

Email address:

*Date & Time Submitted:

*Received From:

*Report to:

Type of Loss:

Policy Dates:

Coverages:

Deductible:

Claim Number:

Policy Number:

Date Of Loss:

Loss Location:

Type of Assignment?

Full Adjustment
Appraisal
Investigation
Ltd. Assignment


Insured Information

 

Name:

Address:

Home Phone:

Work Phone:

Property:

Property Location:

Vin or Lic:

Damages:

Estimate(s):


Claimant Information

 

Claimant:

Address:

Home Phone:

Work Phone:

Property:

Property Location:

Vin or Lic:

Damages:

Estimate(s):

Comments/Instructions:

 

 


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