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Get WI WEA Member Benefits WMBT 2561-290 2019-2024

Odel numbers) Policy Number: Insured: Purchased or Obtained From Claim Number: Date of Loss: Date of Purchase or Age Original Cost New Method of Payment (Cash, Charge, etc.) Current Replacement Cost Cost of Repair or Restore COMPANY USE ONLY Dept/Settlement Amount This above information is true and correct to the best of my (our) knowledge. Insured s Signature Insured s Signature Instructions: Date Date Totals $ $ YOU HAVE JUST SUFFERED A LOSS TO YOUR PERSONAL PROPERTY THAT WI.

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