CLAIMS

1666 20th Street

Suite 200

Santa Monica, CA 90404

310.478.5041

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Insured Organization*
Address*
Street Address 1 Street Address 2 City State ZIP Code
Insured Contact Name*
First Last
Phone*
Email*
Agency Contact Name*
First Last
Contact Phone*
Contact Email*
Comments/Questions
Date of Loss*
MM slash DD slash YYYY
Description of Loss
Has a lawsuit been filed?*
- Yes
- No
Date Served*
MM slash DD slash YYYY
Attachments
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