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Text File  |  1991-06-27  |  558b  |  19 lines
  1. #3600
  2. @001 Enter the name of the insurance company:
  3. @002 Enter the name of the insured:
  4. @360/@360/@360/@360 Enter nature of peril resulting in claim:
  5. Automobile collision
  6. Fire
  7. Theft
  8. KEY IN VALUE
  9. @361/@361/@361 Enter the type of coverage claim was paid under:
  10. Automobile Collision/Comprehensive
  11. Homeowner's
  12. KEY IN VALUE
  13. !362 Enter the amount of the claim in numerals:
  14. !363 Enter the amount of the insured's deductible in numerals:
  15. #3601/#3602 The insured's deductible:
  16. Will be collected by the insuror
  17. Will be retained by the insured
  18. #3603
  19.