PLACE AN ACCOUNT WITH NATIONAL SERVICE BUREAU
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Note: All fields are required.
Client:
Company:
Address:
Name:
City:
Phone:
State:
E-mail:
Zip:
Fax:
Client #:
Adverse Party Information
Adverse Party:
Address:
City:
State:
Zip:
Telephone Number:
Driver License #:
Place of Employment
:
POE Phone
:
Registered Owner Information
Registered Owner
:
Address
:
City
:
State
:
Zip
:
Phone
:
License Plate #
:
Claim Information
Claim Amount :
Property Damage :
PIP/BI:
Salvage:
Towing:
Deductible:
Interest:
Other:
Amount Paid by Adverse:
Date of Loss:
Location of Loss
Adverse Cited :
Yes
No
Judgment:
Yes
No
Prom Note :
Yes
No
License Suspended :
Yes
No
Police Report :
Yes
No
Estimate:
Yes
No
Proof of Payment:
Yes
No
Contact Insured :
Yes
No
Description of Loss:
Insured
:
Telephone Number:
Policy Number :
Claim Number:
Adjuster:
PLEASE REPORT ALL PAYMENT AND COMMUNICATIONS PROMPTLY.
LEGAL ACTION SHALL NOT BE INSTITUTED WITHOUT APPROVAL AND AUTHORIZATION.
WITHDRAWAL OF CLAIMS WILL BE SUBJECT TO OUR STANDARD FEES.
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