Claim Form - Alexander & Strunk Insurance

POLICY INFORMATION
Policy Holder's Name or Company Name:
Your Name (leave blank if same as above):
Type of Policy:
Policy Number:
Preferred method of contact:
E-mail:
Telephone:
Fax:

CLAIM INFORMATION
Location of Claim (address):
Date Claim Occurred:
Describe Claim (Please be specific and include time, and chain of events):
Other Parties Involved (Please be specific and include names and methods of contact is available):

A&S Insurance

Mailing Address

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