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Client Information
Client Name
*
First
Last
Company Name
Email
*
Phone
File No.
Date of Loss
MM slash DD slash YYYY
Insured
Subject Information
Subject's Name
First
Last
Date of Birth
MM slash DD slash YYYY
Address
Street Address
Address Line 2
City
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Province
Postal Code
Occupation
Driver's License
Description of Family
Is the subject is married, kids, spouse, life partner, ages etc.
Subject Description
Upload a photo for Identification
Max. file size: 96 MB.
Incident Details
Vehicles/Plates
Alleged Injuries
Other Insurer
Plaintiff Lawyer
First
Last
Urgent/Important Dates
Financial Limit
Special Instructions
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