EEISC Case Assignment
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E-mail Address: *
Requestor/Claim Rep. *
Telephone/ext. *
Claim/File Number
Date of Loss
Insured
Insured Address/Phone
Claimant
Claimant's Address/Phone
Location Accident - Description
Attorney Information
Requested ServicesLate Notice Statement
Insured's Signed Statement
Tenant Statement
Witness Statement
Photos/Diagram
Measurements/Diagram
Last Lease Agreement
Civil Police Records
Criminal Police Records
Deed/Title From Ins'd
Witness Locate
Witness Canvass
Copy of Work Contract
Copy of Property Survey
Surveillance
Other (See Below)
Police Information
Additional Requests
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