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  *Insured Name on Policy:
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  *Date/Time of Claim:
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  *Description of Claim ( What Happened?):
  *Are there any Injuries?:
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PO Box 2133 Kalamazoo, MI 49003
5136 Lovers Lane Suite 104, Portage, MI 49002
Phone: 269-381-9442               Toll-Free 1-800-315-8740                         Fax: 269-381-8944

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