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 Mine Subsidence: {report_a_claim___Insurance_Available_Mine_Subsidence} Type of Policy: {report_a_claim___Type_of_Policy}
Policyholder Contact Information
Named Insured(s): {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}
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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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