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877-519-3448
Fax:
877-519-3449
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Terry Brown
Steve Chasteen
Darrin Clayton
Logan Fults
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Services
Loss Intake Request
FireTech Loss Intake Request Form
Please provide us with the following information:
CLIENT INFORMATION
Client First Name
Client Last Name
Company Name
Client Address
Address 1
Address 2
City
Country
United States
State/Province
Postal Code
Work Phone
Mobile Phone
Email
INSURED INFORMATION
Insured Name
Insured Phone
Insured Mobile Phone
LOSS INFORMATION
Date of Loss
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AM
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Americas/Chicago
Claim Number
Loss Address
Address 1
Address 2
City
Country
United States
State/Province
Postal Code
Additional Loss Information or Instructions
Submit