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Company Info
General Info
Policy Claims
Supplements
Equipment
Fraud Page
Confirmation
Section 4: POLICY CLAIMS
PLEASE COMPLETE ALL THE ITEMS BELOW FOR YOUR PREVIOUS POLICY INFORMATION:
General Liability
Company
Policy Date
Sales $
Limits
Deductible $
Premium
Property
Company
Payroll $
Property Off Premise
Property Date
Building Value
Limits
Contents
# of Trailers
Premium
Business Income $
Auto
Company
Radius
Policy Date
# of Trucks
Limits
# of Vans
Premium
# of Priv. Pass
Umbrella
Company
Policy Date
Limits
Premium
Please Indicate the claim year, type, quantity, and amount incurred in the last three years: (If none just leave set to none)
Year of claims:
None
2015
2014
2013
2012
Claim Type:
None
Liability
Auto
Property
No. of claims:
Total Amount:
Year of claims:
None
2015
2014
2013
2012
Claim Type:
None
Liability
Auto
Property
No. of claims:
Total Amount:
Year of claims:
None
2015
2014
2013
2012
Claim Type:
None
Liability
Auto
Property
No. of claims:
Total Amount:
Year of claims:
None
2015
2014
2013
2012
Claim Type:
None
Liability
Auto
Property
No. of claims:
Total Amount:
Year of claims:
None
2015
2014
2013
2012
Claim Type:
None
Liability
Auto
Property
No. of claims:
Total Amount:
Submit