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Claim Reporting Instructions 1. Items with * must be completed. Please complete as much of the questionnaire as possible. Upon completion, please click the SUBMIT button . 2. Leave the information you do not have blank. 3. Attach any additional information or documents related on the last page before you submit. 4. If you have any question please contact our Claims Department at 323-987-2333 x 4 or claims@gainins.com. 5. You may call and follow up with our Claims Department once you have submitted your claim.

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