ADJUSTERS INC.

208, 7260 - 12 Street, S.E.

Calgary, Alberta

Canada, T2H 2S5

Tel.  (403) 256-8400

Fax. (403) 256-7289

 
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 Insured
Surname: 
First Name:
Address:
City:
Province:
Postal Code:
Home Phone:
Work Phone: Ext.

 Insurance Company
Name:
Branch:
Policy Number:
Claim Number:
Examiner:
Coverage:
Insured Property:
Agent:

 Loss Details
Date of Loss:
Type of Loss:
Location of Loss:
Other Insurance:
Driver Last Name:
  First Name:
  Details:
 

Handling Instructions:
Adjuster of choice:

 
 

 


 

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