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Get Claim/loss Affidavit (pdf) - Wayne State University - Idrm Wayne

Y TO EVALUATE LOSSES CLAIMED AND POSSIBLE LIABILITIES RELATIVE THERETO; PROVIDED, HOWEVER, THAT ACCEPTANCE OF THIS INFORMATION SHALL NOT BE DEEMED AS CREATING ANY OBLIGATIONS HEREUNDER. NAME TELEPHONE NO. hereby makes claim for: STREET CITY and STATE Property Damage Other as more fully set forth and described below, in the amount of $ , and alleges that said loss occurred on or about 2006 and was discovered on in the following described m.

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