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Ivision of XN Financial Please send us the completed form and any additional information requested by email to uw xnrisk.com, or by fax at 1-877-908-1837. Supplemental Claim Information 1. Claimant(s): 2. Relationship to Assured(s): 3. Defendant(s): 4. Position/Title(s): 5. Claim Status: 6. Venue (Court or Administrative Agency): 7. Date of act(s) causing claim / incident: MM-DD-YYYY 8. Date claim / incident reported to the applicant: MM-DD-YYYY 9. Description of Claim and a.

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