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New Assignment for Dakota Claims Service of Rapid City
Your Contact Information
First Name
Last Name
Company
Address (Line 1)
(Line 2)
City
State	AAABAEAKALAPARAZBCCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMBMDMEMIMNMOMSMTNBNCNDNENFNHNJNMNSNTNUNVNYOHOKONORPAPEPRQCRISCSDSKTNTXUTVAVTWAWIWVWYYT
ZIP
Phone:
eMail:
New Assignment Information
Your Claim #:
Assignment Instructions: Characters left:
Insured's Information
Policy #:
Phone #:
Alternate Phone #:
Company:
First Name:
Last Name:
Street Address:
Address 2:
City:
State:	AAABAEAKALAPARAZBCCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMBMDMEMIMNMOMSMTNBNCNDNENFNHNJNMNSNTNUNVNYOHOKONORPAPEPRQCRISCSDSKTNTXUTVAVTWAWIWVWYYT
Zip:
Mortgagee:
Loss Location
Street Address:
Address 2:
City:
State:	AAABAEAKALAPARAZBCCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMBMDMEMIMNMOMSMTNBNCNDNENFNHNJNMNSNTNUNVNYOHOKONORPAPEPRQCRISCSDSKTNTXUTVAVTWAWIWVWYYT
Zip:
Claimant Information (if applicable)
First Name:
Last Name:
Phone:
Street Address:
Address 2:
City:
State:	AAABAEAKALAPARAZBCCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMBMDMEMIMNMOMSMTNBNCNDNENFNHNJNMNSNTNUNVNYOHOKONORPAPEPRQCRISCSDSKTNTXUTVAVTWAWIWVWYYT
Zip:
Agent Information Show | Hide
First Name:
Last Name:
Company:
Office Phone:
Cell Phone:
Street Address:
Address 2:
City:
State:	AAABAEAKALAPARAZBCCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMBMDMEMIMNMOMSMTNBNCNDNENFNHNJNMNSNTNUNVNYOHOKONORPAPEPRQCRISCSDSKTNTXUTVAVTWAWIWVWYYT
Zip:
Country:
Loss Information
Date of Loss:
Type of Loss:	HailWindHail and/or WindWaterFireFloodLightningLiabilityInvestigationCollisionComprehensive/OTCWork CompProduct LiabilityWater/FreezeSewerWater/SewerWater / Plumbing or Sump Pump failureIce/SnowCollapseVandalismSmokeTheftElectricalFreezingProperty DamageProperty AppraisalCargo LossMold/RotWeather and/or Storm Fire/SmokeSlip and/or FallBurglaryUnknown Other
Unit:	AutoResidential PropertyCommercial PropertyCommerical LiabilityCommercial AutoMobile HomeHeavy EquipmentDwellingBusiness OwnersWork CompFarm/RanchBuilders RiskBoatATV / UTVMotorcycleInland MarineGarage PolicyTruck Collision or Loss Cargo lossFarm/Livestock EquipLivestockRV/CamperRentersTrailersAntique/CollectibleLiabilityDealer LotWatercraftOther
Type of Adjustment:	Limited Full
Loss Description: Characters left:
VIN #:
Deductible:
Wind Deductible:
Coverage A
Coverage B
Coverage C
Coverage D
Endorsements:
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