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Get Coverys Authorization To Release Claim History And Coverage Verification Form 2014

E your own form as long as it contains identifying information and is duly signed and dated. There is a $30 fee* for a loss history report. Please send the completed form and a check payable to Coverys to: Coverys Claim Information & Reporting Unit P.O. Box 55178 Boston, MA 02205-5178 * Current insureds receive one report free per calendar year. All other requests will be assessed a $10 charge. Type or Print Name of Provider: Name of Group or Organization: Current Mailing Address: Phone Numbe.

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