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Gallagher Bassett Services, Inc - Download as DOC by cFpU4xbV

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									        Gallagher Bassett Services, Inc.


                           Fax Cover Sheet
Date:                                               Fax:        800-953-8414

 To:                   Gallagher Bassett Claims Reporting

  Re:             WORKERS’ COMPENSATION, AUTO and
                  GENERAL LIABILITY FIRST REPORTS

                                                   Pages: (including cover)



        REQUIRED INFORMATION (please print):
        (Gallagher Bassett must have the following information in order to assist
                in the timely completion of the first report. Thank you.)
         GB Client Number: 010641
         GB Client Name: Dow Jones
         Indicate Report Type (check one)
            o Workers’ Compensation
            o General Liability
            o Auto Liability
         Date/Time of Accident:


         Date/Time Client Notified:


         Claimant Name:


         Risk Location Code (or city, state, zip code of the
         employer location)



                             CLIENT CONTACT:
         Name:
         Email Address:
         Phone Number:

								
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