William A. Reynolds Associates

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Your first name:

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Title

Company

Office Phone

Mobile Phone

Insured Information

Insured Name

Loss location

City

State

Connecticut Maine Massachusetts New Hampshire Rhode Island Vermont

Zip Code

Contact

Home Phone

Work Phone

Mobile Phone

Claim Information

Claimant Name (if applicable)

Claim Number

Claim Type

First Party Bodily Injury Liability Property Damage Liability

Policy Number

Date of Loss

Type of Loss

Assignment

Special Instructions

Are you human? What is 10 + 2?

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