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Loss Run Request Form

*Your Name:
*Agency Name:
Insured Name:
*Policy Number:
Policy Term:
Policy Number:
Policy Term:
Policy Number:
Policy Term:
How would you like us to respond?
*Email:
Fax:
 
Any person, who knowingly and with intent to defraud any insurance company or any other person, files an application for insurance containing false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime. This application does not bind any of the parties to complete the insurance transaction.