Fax Record Request
VIA FAX: (480) 730-5116
| CLAIMANT/INSURED: | _____________________________________________________ | |
| DATE OF LOSS: | _____/____/__________ (mm/dd/yyyy) | |
| LOST INCOME CLAIMED: $ | ____________________ (leave blank if unknown) | |
| OCCUPATION/BUSINESS: | _____________________________________________________ | |
| ESTIMATED LOSS PERIOD: | ________ Weeks or ________ Months | |
| CASE OVERVIEW: (optional) |
_____________________________________________________ | |
| _____________________________________________________ | ||
| _____________________________________________________ | ||
| _____________________________________________________ | ||
| _____________________________________________________ |
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(Return this portion with payment) |
| YOUR NAME: | ___________________________________ | FILE#: | ______________________ |
| COMPANY: | ___________________________________________________________________ | ||
| ADDRESS: | ___________________________________________________________________ | ||
| CITY: | ___________________________________ | STATE: | ______________________ |
| ZIP: | ___________________________________ | DATE: | _____/____/____________ |
| TIME: | ______________________ | ||
| PHONE: | ___________________________________ | FAX: | ______________________ |
| NOTE: Please detach and remit $95.00 payable to: EZ DOC |
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