CL*****B-NW-TIP*-****
© **** Assurant, Inc.
[Month Day, Year]
Account Number [XXXXXXXXX]
[IIIIIIIIIIIIIIII barcode IIIIIIIIIIIIIIIIIIIII]
[Sample A. Sample]
[Street Address]
[City, ST XXXXX-XXXX]
● Loss
● Theft
● Accidental damage (including liquid damage)
● Mechanical or electrical...