Different Type Of Account – Thomas George Associates LTD

Place a Different Type of Account

Assignment Information
Type of Assignment
- Deductible Recovery
- Earned Premium
- Claim Overpayment
- Audit Premium
- Unearned Commission
- Other
Client Name
Date
Month
Day
Year
Phone
Address
Street Address Address Line 2 City State ZIP Code
Assigned By
First Last
Submitter's Email Address
Responsible Party Information
Name of Responsible Party
First Last
Address of Responsible Party
Street Address Address Line 2 City State ZIP Code
Phone
Case Number
Total Balance Owed ($)
Comments or Questions?
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If you are experiencing problems uploading documentation, please send them in an email along with your case number to [email protected].