HiddenSubmit User HiddenLogged In User Name(Required) HiddenLogged In User Email HiddenCurrent Post ID Task SelectionMake Selection30 Day Letter30 Day Letter - CMS (Extraction Only)Medical LetterNon-Medical LetterDebris Challenge With OrdinanceExtrication ChallengeHazMat ChallengeHB-131 ChallengePrior W/Ordinance ChallengePrior with NO Ordinance ChallengeDebris with NO Ordinance ChallengeFree Public Services DoctrineSafe Auto vs McKean Hose CompanyScotch Plains Court LetterWhitehall Citation LetterSFRS - Cannot Locate Claim ResponseSFRS - Check Cancellation ResponseSFRS - Damaged Equip ResponseSFRS - Denial of Claim Without ReasonSFRS - Explanation of Changes ResponseSFRS - Not A Medical Claim ResponseSFRS - Payment Promised - Not Issues ResponseSFRS - Previous Claims Paid ResponseSFRS - Property & Bodily InjuryFire Department ChoicesSelect Fire Department Federal ID NumberAL-01-403AL-01-712AL-01-717AL-01-811AL-02-006AL-02-908AL-05-022AL-06-203AL-06-327AR-23-003FL-51-061KY-00-814KY-00-921LA-05-025MO-01-508MO-04-308MO-05-307MO-05-309MO-05-310MO-06-607MO-07-714OK-16-015OK-16-016OK-41-016OK-49-004OK-49-007OK-49-008OK-49-013OK-49-015OK-49-016OK-55-024OK-59-007OK-67-007OK-72-015OK-73-148TX-AC-309TX-AC-405TX-AC-409TX-AK-305TX-AW-302TX-AZ-409TX-BB-430TX-BH-501TX-BY-204TX-BY-205TX-CN-310TX-CW-201TX-CX-409TX-GH-311TX-GS-309TX-GS-417TX-HK-101TX-HN-403TX-HP-309TX-HP-401TX-HS-403TX-HW-404TX-HW-405TX-KB-403TX-KB-509TX-KP-401TX-KP-403TX-KS-406TX-PG-301TX-PP-203TX-PR-309TX-PT-303TX-PZ-402TX-RG-207TX-RG-210TX-RN-424TX-RN-428TX-SD-508TX-SH-101TX-SH-201TX-SH-214TX-WB-206TX-WZ-208TX-XP-405TX-XP-612TX-XR-403Fire Department Insurance Company ChoicesSelect Insurance Company NameAAA Texas County Mutual InsuranceAARP AUTO INSURANCEACCC INSURANCEACCC Insurance CompanyAce American InsuranceAcord Insurance-MedicalAcuity A Mutual InsuranceAdvanced Insurance GroupAffinity - Claims DepartmentAgricultural Workers Mutual Auto Insurance Co. 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Help, Inc.ZURICH NORTH AMERICAHiddenPost TItle HiddenCompany Name Address City State Zip Name First Last Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Incident Number Date of Loss MM slash DD slash YYYY Arrival TimeTime is to be entered in as military time 1PM = 13:00 Hours : Minutes Policy # Policyholder Names Patient Name Accident TypeSelect OneSingle VehicleMulti-VehicleIncident TypeSelect OneMVA RESPONSEMVA WITH ENTRAPMENT RESPONSESTRUCTURE FIRE RESPONSEVEHICLE FIRE RESPONSEFIRE DEPARTMENT RESPONSEUNCONTROLLED BURN RESPONSEHAZARDOUS MATERIAL RESPONSEIncident Address Receipt Date of Letter MM slash DD slash YYYY Invoice AmountDue Date MM slash DD slash YYYY Adjuster Name Check Amount From Ins CompanyDate of Check from Insurance Company MM slash DD slash YYYY Date Check Was Cancelled MM slash DD slash YYYY Ordinance Information Damaged Item Questioned Charge Description Questioned Item Missing Payment AmountMissing Item To Be Paid