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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
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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
*
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