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* Adjuster:
* Phone:
* Your Email:
* Region:	Select One WESTRO MSTRO CENTRAL SERO SWRO MARO NE/OVERSEAS
* Your Unit:	Litigation Unit Non Litigation Unit
* Line of Business:	Liability UM/UIM
* Member Number:
* Member Name:
* Date of Loss:
* Location of Loss:
* Injury:
* Claimant:
Claimant's Gender:	Male Female
Claimant's Birth Date:
Total Offer:
Dependents:
Annuity Amount:
Defense Attorney:
Defense Attorney Phone:
Defense Attorney Fax Number:
Plaintiff Attorney:
Plaintiff Attorney Phone:
Plaintiff Attorney Fax Number:
* Send this form to:	Choose One Claire Blajsczak John W. Cameron Michael W. Goodman William S. Goodman Rolf H. Koseck Jon Romanishin Kelly Settles Thomas W. Stockett Daniel D. Vickovic Justin W. Moseley
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