Imperial Jewelers

Your File#
Insured Name
Claimant Name
Residence Address		Phone

City	State	Zip
Business Address		Phone

City	State	Zip
Description of Items
Term
Date of Loss	Reported
Partial Loss Complete Loss
History or Pertinent Facts/Loss Location if Different From Above
Appraised By
Purchased From
Insurance Company
Policy#
Adjuster Name
Adjuster Phone	Adjuster Fax
Amount Insured	Deductible Amount
Agency
Public Adjuster

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