Company Name:

Contact Name:

Contact Phone Number:

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Date of Claim:

Description of Claim:

I affirm I have submitted information correctly to the best of my knowledge. I consent to have Citadel Insurance Services submit my claim information to the insurance carrier. I understand and agree that the insurance company will rely on my statements in this form. I understand that submitting a claim does not guarantee any coverage or defense from the insurance carrier for such claims.

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