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New Assignment for Hammerman & Gainer, Inc.
Your Contact Information
First Name
Last Name
Company
Address (Line 1)
(Line 2)
City
State	AAABAEAKALAPARAZBCCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMBMDMEMIMNMOMSMTNBNCNDNENFNHNJNMNSNTNUNVNYOHOKONORPAPEPRQCRISCSDSKTNTXUTVAVTWAWIWVWYYT
ZIP
Phone:
eMail:
New Assignment Information
Your Claim #:
Assignment Instructions: Characters left:
Insured's Information
Policy #:
Phone #:
Alternate Phone #:
Company:
First Name:
Last Name:
Street Address:
Address 2:
City:
State:	AAABAEAKALAPARAZBCCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMBMDMEMIMNMOMSMTNBNCNDNENFNHNJNMNSNTNUNVNYOHOKONORPAPEPRQCRISCSDSKTNTXUTVAVTWAWIWVWYYT
Zip:
Mortgagee:
Loss Location
Street Address:
Address 2:
City:
State:	AAABAEAKALAPARAZBCCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMBMDMEMIMNMOMSMTNBNCNDNENFNHNJNMNSNTNUNVNYOHOKONORPAPEPRQCRISCSDSKTNTXUTVAVTWAWIWVWYYT
Zip:
Claimant Information (if applicable)
First Name:
Last Name:
Phone:
Street Address:
Address 2:
City:
State:	AAABAEAKALAPARAZBCCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMBMDMEMIMNMOMSMTNBNCNDNENFNHNJNMNSNTNUNVNYOHOKONORPAPEPRQCRISCSDSKTNTXUTVAVTWAWIWVWYYT
Zip:
Agent Information Show | Hide
First Name:
Last Name:
Company:
Office Phone:
Cell Phone:
Street Address:
Address 2:
City:
State:	AAABAEAKALAPARAZBCCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMBMDMEMIMNMOMSMTNBNCNDNENFNHNJNMNSNTNUNVNYOHOKONORPAPEPRQCRISCSDSKTNTXUTVAVTWAWIWVWYYT
Zip:
Country:
Loss Information
Date of Loss:
Type of Loss:	FireFloodHailHurricaneLiabilityTheftVandalismWaterWindWorkers' CompensationOther
Unit:	FloodDaily - ResidentialDaily - CommercialLiability- PersonalLiability- CommercialCATASTROPHEAutoOtherOther OtherMisc
Type of Adjustment:	Limited Full
Loss Description: Characters left:
VIN #:
Deductible:
Wind Deductible:
Coverage ABuilding Other StructuresPersonal PropertyLoss of Use / ALEBusiness Personal PropertyBusiness Income InterruptionLiability *******************************Appurtenant Unit Covered DamageAppurtenant Unit Gross Loss RCVAppurtenant Unit Gross Loss RCVBuilding Covered Damage ACVBuilding Gross Loss RCVBuilding Property Value ACVBuilding Property Value RCVBuilding Removal ProtectionBuilding Replacement CostBuilding SalvageContents Property Value RcvContents Property Value AcvContents Gross Loss RcvContents Covered Damage AcvContents Removal ProtectionContents Salvage
Coverage BBuilding Other StructuresPersonal PropertyLoss of Use / ALEBusiness Personal PropertyBusiness Income InterruptionLiability *******************************Appurtenant Unit Covered DamageAppurtenant Unit Gross Loss RCVAppurtenant Unit Gross Loss RCVBuilding Covered Damage ACVBuilding Gross Loss RCVBuilding Property Value ACVBuilding Property Value RCVBuilding Removal ProtectionBuilding Replacement CostBuilding SalvageContents Property Value RcvContents Property Value AcvContents Gross Loss RcvContents Covered Damage AcvContents Removal ProtectionContents Salvage
Coverage CBuilding Other StructuresPersonal PropertyLoss of Use / ALEBusiness Personal PropertyBusiness Income InterruptionLiability *******************************Appurtenant Unit Covered DamageAppurtenant Unit Gross Loss RCVAppurtenant Unit Gross Loss RCVBuilding Covered Damage ACVBuilding Gross Loss RCVBuilding Property Value ACVBuilding Property Value RCVBuilding Removal ProtectionBuilding Replacement CostBuilding SalvageContents Property Value RcvContents Property Value AcvContents Gross Loss RcvContents Covered Damage AcvContents Removal ProtectionContents Salvage
Coverage DBuilding Other StructuresPersonal PropertyLoss of Use / ALEBusiness Personal PropertyBusiness Income InterruptionLiability *******************************Appurtenant Unit Covered DamageAppurtenant Unit Gross Loss RCVAppurtenant Unit Gross Loss RCVBuilding Covered Damage ACVBuilding Gross Loss RCVBuilding Property Value ACVBuilding Property Value RCVBuilding Removal ProtectionBuilding Replacement CostBuilding SalvageContents Property Value RcvContents Property Value AcvContents Gross Loss RcvContents Covered Damage AcvContents Removal ProtectionContents Salvage
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