House Claim
  1. Homeowners Claim
  2. First Name
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  3. Last Name
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  4. Address
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  5. City
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  6. Province
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  7. Postal Code
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  8. How would you like us to contact you?
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  9. Daytime Phone
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  10. Night-time Phone
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  11. Best Time To Call
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  12. Email Address
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  13. Number of propertles you want to claim
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  14. Date of Loss
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  15. Time of Loss
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  16. Location of Accident or Claim
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  17. Cause of Accident or Claim
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  18. Description of Accident or Claim
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  19. Authority Contacted
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  20. Report Number
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  21. Please give any additional comments you feel appropriate for this claim.
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  23. First Name
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  24. Last Name
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  25. Current Email Address
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  26. Submit This Form
      
 

DeHart & Stauffer Insurance Brokers Copyright © 2014. All rights reserved.
843 King Street WestOshawa, Ontario L1J 2L4 (905) 576-2234Fax 1-253-550-4655