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1. Policy No. :
2. Nature Of Loss :
3. Insured :
4. Address :
5. Contact Person :
6. E-mail :
7. Contact Tel. No :
8. Address of Survey :
9. Type of property / vehicle no. :
10. Sum Insured :
11. Excess :
12. Estimate of Loss :
13. Person Giving Assignment :
14. Company :
15. Specific Instructions :

  

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