Adjuster*
Phone*
Email*
Branch Office
Claim Number*
Underwriting Company
Insured*
Date of Loss (mm/dd/yyyy)*
Location of Loss*
Line of Business LiabilityUM/UIMWC
Injury*
Claimant*
Claimant's Birth Date (mm/dd/yyyy)
Claimants Gender* MaleFemale
Names of Parent(s)/Natural Guardian(s), if applicable.
Dependents
Total Offer
Annuity Amount
Defense Attorney
Defense Attorney Phone
Defense Attorney Email
Defense Attorney Fax
Plaintiff Attorney
Plaintiff Attorney Phone
Plaintiff Attorney Email
Plaintiff Attorney Fax
Send This Form To* I Don't KnowKristen ChessClaire DeVanMichael W. GoodmanWilliam S. GoodmanPaula RubinsteinLeigh Ann SmithChristine ComuladaMike Wostoupal
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