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Fill and Sign the Academic Transcript Request Form Boston College Bc

Fill and Sign the Academic Transcript Request Form Boston College Bc

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THIRD PARTY (GENERAL) ACCIDENT REPORT FORM Branch Policy No Claim No This form should be completed and returned to the Insurers immediately, whether a claim has been made on the Insured or not. 1. Name of Insured Address of Insured Business Address Telephone No. 2. Place of Accident Date of Accident Time of Accident 3. If the accident occurred on premises occupied by the Insured and was due to a defect in th premises, who is responsible for maintenance and repair of the property? 4. Please explain how the accident occurred 5. Nature and extent of injury or damage 6. (a) Name of Injured Person Age of Injured Person Addres of Injured Person (b) Name of owner of property damaged Address of owner of property damaged (c) Is he or she in your service? Yes No 7. State whether any claim has been made upon you, with details of amount, if known. If the claim is in writing please forward the communication to us unanswered. 8. When, and by whom was the accident reported to you 9. Names and addresses of witnesses to accident Names Addresses 10. Give the number of the policeman, if any, who took particulars. I/We hereby declare that to the best of my/our knowledge and belief, the above statements are fully and truly made. I/We further declare that the statements above can be relied upon in the contemplation of litigation proceedings which may arise. Date Insured's Signature Print Form Email to Globe

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