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IN-PERSON STATEMENTS FORM
Flat fee (written or recorded). Tapes included

(Task claims assignment sheet sent to Everglades Claims Investigations)

*Company Name

(Claims Department)

*Company Address

*Company Claim Number

*Date of Loss (mm/dd/yyyy)
/ /

*Insured Employer

*Insured Employer Location Number

*Insured Employer Address

*Insured Employer Phone (include area code):
( )

*Claimant

*Claimant Address

*Claimant Phone (include area code):
( )

*Examiner Name

*Examiner Ext.

*Examiner E-mail

Limited Investigation to include statements of:

Statement 1

Statement 2

Statement 3

ATTACHMENTS: If you wish to send incident or claims reports, please attach them to a separate e-mail addressed to ABerg65277@aol.com. Please reference the Company Claim Number listed above in the email.

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