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/ / NOTIFICATION PART I INSURANCE CO.: ADDRESS: DATE REPORTED: NAIC COMPANY #: D.O.L.: POLICY#: CLAIM #: (if available) SIU #: (if available) TELEPHONE #: CONTACT PERSON: E-MAIL ADDRESS: TYPE OF COVERAGE (check appropriate box) LIFE W.C. AUTO HOME COMM. OTHER STATUS (indicate as appropriate) PENDING PAID - IN FULL DENIED PAID - IN PART AMT. PAID: $ DATE / RANGE PD.: IF PENDING OR DENIED, EITHER IN FULL OR IN PART, THE DOLLAR AMOUNT OF THE PENDING OR DENIED CLAIM: $ INSURED LAST NAME FIR.

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