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New Assignment for FIA Group, Inc.
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| Your Contact Information |
| First Name |
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| Last Name |
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| Company |
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| Address (Line 1) |
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| (Line 2) |
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| City |
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| State |
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| ZIP |
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| Phone: |
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| eMail: |
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| New Assignment Information |
| Your Claim #: |
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Assignment Instructions:
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| Insured's Information |
| Policy #: |
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| Phone #: |
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| Alternate Phone #: |
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| Company: |
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| First Name: |
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| Last Name: |
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| Street Address: |
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| Address 2: |
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| Mortgagee: |
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| Street Address: |
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| Claimant Information (if applicable) |
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| Address 2: |
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| First Name: |
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| Company: |
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| Office Phone: |
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| Cell Phone: |
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| Street Address: |
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| Address 2: |
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| Country: |
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| Loss Information |
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Date of Loss: |
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| Type of Loss: |
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| Unit: |
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| Type of Adjustment: |
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Loss Description:
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| VIN #: |
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| Deductible: |
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| Wind Deductible: |
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| Endorsements: |
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