Customer Name (Full Name of Owner/Company)              

  Address of Owner

   Street:

   City:       State:    Zip Code:

    Home Phone:         Work Phone:

    Cell phone/pager    Fax:

    E-mail: 

    Best Time for Contact:

                           Insurance Information

                             Location of the Property (Address)

City: CA    Zip Code:

Insurance Co:    Claim#

Phone:     Ext:    

Fax:

         Date of Loss:                              Agent/Adjuster

              Enter Loss Details: or fax Details to (310) 216-0048

    

 

 

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Last modified: 03/23/07  EVR-GARD CONSTRUTION, PC Help Los Angeles and their affiliates assume no liability for incorrect information provided within this web site. Although mistakes are not intentional, clerical and/or human error does occur. for complete and accurate information please call EVR-GARD CONSTRUCTION @ 1(800) 457-7585