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Get Report Of Settlement, Judgement Or Arbitration Award In Excess Of $3000. Report Of Settlement

Judgement or Arbitration Award In Excess of $3000 (Submit within 30 days of Disposition) Name of Insurance Company, Address and phone number: Insured s Name and License Number (if available): Insured s Address Name of Court/Date of Filing/Docket Number: Plaintiffs/Claimant s Name & Address: Brief Description of Facts upon which claim was made, Date of Loss/Injury: Form RRS Dev 7/2012 Name and Address of Plaintiff s Counsel Names and Addresses of all of the defendant s couns.

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