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Claim Report
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Drag and drop csv file with emails
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Import
COD Claim Report (Multi-use)
Enter your full name
Legal Name of Claimant
*
Enter a # capable of SMS
Phone Number
*
Phone
form field Phone Number
must be in the format: (000) 000-0000
Enter your work email address
Email
*
Email
form field Email
is not in correct form
Address
*
Date of Loss
*
Date
form field Date of Loss
must be in the format: MM/dd/yyyy
Property Damage
*
Property Damage
Yes
No
Injury
*
Injury
Yes
No
Location of Damage or Injury
*
Please Provide a brief description of the damage or injury. Attach Pictures, if available
*
Pictures and Attachments for injury or property damage
Form field Pictures and Attachments for injury or property damage has
Invalid files.
Witness name and Contact information
Is there an estimate or Invoice Avaialble?
*
Is there an estimate or Invoice Avaialble?
Yes
No
Estimate or invoice for this claim report
*
Form field Estimate or invoice for this claim report has
Invalid files.
Signature
*
Type
Draw
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Signature
form field Signature
is required
Email Address:
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