Contact 1 — ProClaimS

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New Assignment

To submit a New Assignment, fill out this form and click the Submit button when completed. Please provide all information to ensure proper handling of your claim.

Please note, fields with the asterisk (*) are mandatory.

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Incident

YYYY

Insured's Name / Phone

Deductible

Details About The Incident

Submit Assignment

New Assignment

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