Single Placement Form

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Individual claims can be submitted online using the form below or simply e-mail them to newclaim@transubro.com. If you have any questions on claim submission please be sure to contact us at (516) 341-7256.

YOUR COMPANY INFORMATION

Company Name *

Company Name Select *

Alt Customer ID *

Division/Region

Store Number *

Contact Name *

Telephone

Fax

E-mail

Address

Address 1

Address 2

City

State/Province

Zip/Postal

Country

ADVERSE INSURANCE COMPANY

Company Name

Contact Name

Telephone

Fax

Secondary Telephone

Email Address

Address

Address 1

Address 2

City

State/Province

Zip/Postal

Claim Number

PLACEMENT DETAIL

Name of Responsible Party

Name of Responsible Party Insurance Company Name of Responsible Party Insurance Company

Date of accident

State in Which Accident Occurred

Were Property Damages Paid? *

Yes

If Yes, How Much in Property Damages Paid?

Do You Have a Police Report? *

Yes

Do You Have a Repair Estimate? *

Yes

Do You Have Photos of the Damages? *

Yes

Customer Number *

If you are human, leave this field blank.

SINGLE PLACEMENT FORM

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YOUR COMPANY INFORMATION

ADVERSE INSURANCE COMPANY

PLACEMENT DETAIL

DOCUMENTATION