PIRA Investigations & Claim Services
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Assignment Referral

Please complete this form and email to PIRA Investigations & Claim Services by simply hitting the Submit button below.  Or, you may call in your assignment if you prefer.

Date: Insured/Client:
Company/Firm: Address:
Contact Person: City, State & Zip:
Address: Phone:
City, State & Zip: Date of Loss:
Phone: Claim/File Number:
Fax:    
Email:    
       
Injured Party/Clmt:    
Address:    
City, State & Zip:    
Phone:    
       
Facts of Loss:
Tasks:
Special Instructions:

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PIRA Investigations & Claim Services
PO Box 390 Lakehead, CA 96051		 Phone: 530-238 8801
Cell: 530-410-4377
Fax: 530-238-8809
Email: piraclaims@att.net www.pirainvestigationsclaimservices.com
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