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SUBMIT A CLAIM

Client Information

Company Name

Street Address

Street Address Line 2

City

Region/State/Province

Postal / Zip code

Assigned Adjuster

Phone

Email

Loss Notice / Claim Information

Claim Number

Date of Loss

Applicable Deductible

Loss Type (Ex: Collision, Comp.)

Loss Description

Insured Information

Insured Name

Claimant Name

Street Adress

Street Address Line 2

City

Region / State / Province

Postal / ZIP Code

Phone

Property Description

Year

Make

Model

VIN/HIN

Location of Property

Adjuster Comments

Thanks for submitting your claim!

P.O. Box 7116 | D'Iberville, MS 39540

info@hansenclaims.com | 228-697-3133

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