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Intake
Claim Intake
All sections highlighted in yellow must be completed. If the submitter does not have all the information, the intake form can be saved as an incident until such time as all the pertinent information is obtained.
Submitter Information
Submitter Name
Title
Day Phone
Evening Phone
Submitter Email
Claim Details
What happened ?
Where did it happen?
What injuries or expenses resulted ?
When do you think it happened ?
Confirm Changes
Valid Start Date
* leave date blank if change applies from beginning of time
Valid End Date
* leave date blank if change applies until end of time
Add attachments
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Yes
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