Network Claims Solutions, Inc.
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 Insurance Company/Claim Information
*Insurance Company Name
*Contact Person Name
*Contact Phone
*Contact Email
*Claim Number
*Date of Loss
Pick Date    MM/DD/YYYY

 Owner Info
 Owner First Name
*Owner Last Name/Company Name
*Owner Address
*Owner Zip Code
*Owner City,State
*Owner Phone
 Owner Email
 Claimant Liable

 Vehicle Info
*Vehicle Year
 Vehicle Type
*Vehicle Make
 Vehicle Make Other
*Vehicle Model
 VIN (last 6 digits are a minimum)
 License Plate
 Vehicle at Residence
*Vehicle Location Name
*Vehicle Location Address
*Vehicle Location City, State
*Vehicle Location Zip
*Vehicle Location Phone
*Primary Damage on the Vehicle
 Secondary Damage on the Vehicle
 Damage Severity
 Airbag Deployed
 Vehicle Mileage
 Vehicle repair intended
 Rental Required
 Injury involved

 Special Instructions

 Misc. Attachment
 Misc. Attachment
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 NCS will consider this submission as an active assignment, if the assignment
 is not canceled within 12 hours from the time of submission, you will be
 billed for this assignment, unless otherwise agreed upon prior to sending the
 assignment. This does not pertain to our contract or volume customers.© 2007 - 2019 NCS North, Inc.