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REPORT A CLAIM
 
 
 REQUIRED INFORMATION
Insured Name:
*
Phone Number:
*
E-mail Address:
*
Reporter's Name:
*
Phone Number:
*
E-mail Address:
*
Tipe of Lost:
*
Day & Time Loss:
*
Location:
*
Description:
Authority Contacted:
*
Additional comment:
 

Disclaimer: Submission of a loss notice does not represent, assure or guarantee that coverage will be provided by your insurance program. If further information is required, you will be contacted by either a representative of Seitlin or your insurance company.

 

Any person who knowingly, and with the intent to injure, defraud, or deceive any insurance company, files a statement of claim containing any false, incomplete or misleading information is: guilty of a felony and/or subject to criminal prosecution, civil penalties; punishable by imprisonment or fines


 
Our agents will contact you as soon as possible.
 
REGISTRATION
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