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- #3600
- @001 Enter the name of the insurance company:
- @002 Enter the name of the insured:
- @360 Enter nature of peril resulting in claim:
- @361 Enter the type of coverage claim was paid under:
- @362 Enter the amount of the claim in numerals:
- @363 Enter the amount of the insured's deductible in numerals:
- #3601/#3602 The insured's deductible:
- Will be collected by the insuror
- Will be retained by the insured
- #3603