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Hourly rate

(Full investigation sent to Everglades Claims Investigations)

*Company Name

(Claims Unit:)

*Claims Unit Address

*Examiner Name

*Examiner Phone (include area code):
( )

*Examiner E-mail

Assignment sheet:

*Company Claim Number

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

*Insured Employer


*Claimant Address

*Claimant Phone (include area code):
( )

Statements from:

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 Please reference the Company Claim Number listed above in the email.

Additional Requests and/or Comments

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