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Physical Address (required)
Postal Address (required)
Address where loss occured
Time of loss
Loss Date (required)
Describe fully how the loss occured
Was the premises occupied?
If not when was it last occupied
Estimate the value of the damaged property
Is the the destroyed property insured on another policy?
If Yes State Insurer
Any additional Comments
Attach 3 Quotations from reputable garage below
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