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First Name
Middle Name
Last Name
Company Name
Address Line 1
Address Line 2
City
State
Zip Code
Country
Daytime Phone() -
Fax() -
E-mail Address
Insured First Name
Insured last name
Insured street address
Insured city
Insured state
Insured work phone
Insured home phone
Claimant first name
Claimant last name
Claimant street address
Claimant City
Claimant State
Claimant work phone
Claimant home phone
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You may also submit an assignment by sending it to our general e-mail: info@protocolinsurance.com or via our Fax 702.838.0536 or you may choose to call it in directly at our voice line of 702-838.0536

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