Illinois Mine Subsidence Insurance Fund

ID: {report_a_claim___id}
Date: {report_a_claim___date_time}


Insurer Information

Insurer: {report_a_claim___Insurer}
Policy Number: {report_a_claim___Policy_Number}
Policy Start Date: {report_a_claim___Policy_Start_Date}
Policy End Date: {report_a_claim___Policy_End_Date}
Amount of Insurance Available for Fire: {report_a_claim___Insurance_Available_fire}
Amount of Insurance Available for Subsidence: {report_a_claim___Insurance_Available_Mine_Subsidence}
Type of Policy: {report_a_claim___Type_of_Policy}


Policyholder Contact Information

Named Insured: {report_a_claim___Named_Insured}
Address Of Insured Location: {report_a_claim___Address_Of_Insured_Location}
City: {report_a_claim___City}
County: {report_a_claim___County}
Zip: {report_a_claim___Zip}
Home Phone: {report_a_claim___Home_Phone}
Cell/Work Phone Number: {report_a_claim___Cell_Work_Phone_Number}

Mailing Address Information
Address: {report_a_claim___Mailing_Address}
City: {report_a_claim___Mailing_City}
State: {report_a_claim___Mailing_State}
Zip: {report_a_claim___Mailing_Zip}


Information On The Loss

Claim Number: {report_a_claim___Claim_Number}
Date Of Loss: {report_a_claim___Date_Of_Loss}
Date Policyholder Reported Loss To Insurer: {report_a_claim___Date_Reported_Loss_To_Insurer}
Inception Date Of Mine Subsidence Coverage: {report_a_claim___Inception_Date_Of_Mine_Subsidence_Coverage}
Estimated Reserve: {report_a_claim___Estimated_Reserve}

Claim Supervisor Information

Name: {report_a_claim___Claim_Supervisor_Name}
Mailing Address: {report_a_claim___Claim_Supervisor__Mailing_Address}
City: {report_a_claim___Claim_Supervisor_City}
State: {report_a_claim___Claim_Supervisor_State}
Zip: {report_a_claim___Claim_Supervisor_Zip}
Phone: {report_a_claim___Claim_Supervisor_Phone}
Email: {report_a_claim___Claim_Supervisor_Email}


Assistance

{report_a_claim___Assistance_Type}


Comments

{report_a_claim___Comments}

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