EIB 07-01A, Sectio Electronic Claim Filing System, Short-Term Insurance

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Short-term Multi-buyer Policy Claim
Section A - Names and Addresses

( * An asterisk denotes that a field is a required entry)

Insured
Name: *
Address Line 1: *
Address Line 2: *
Address Line 3: *
City: *
State: *
Zip: *
Contact Name: *
Phone: *
Fax: *
E-Mail: *

Assignee
Click here if not
*
Not Applicable
applicable
Assignment
Enhanced
Regular
Type
Day
Assignment Date: Month
, Year
Name:
Address Line 1:
Address Line 2: *
Address Line 3: *
City:
State:
Zip:
Contact Name: *
Phone: *
Fax: *
E-Mail: *

https://tpccapps.exim.gov/apps/ecfs/ecfsprod.nsf/0/1ABA8340947C1CEE852572A4004D...

3/20/2007

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Buyer
Name: *
Address Line 1: *
Address Line 2: *
Address Line 3: *
City: *
Country *
Contact Name: *
Phone: *
Fax: *
E-Mail: *

Guarantor
Click here if not
applicable
Name:

Not Applicable

Address Line 1:
Address Line 2: *
Address Line 3: *
City:
Country
Contact Name: *
Phone: *
Fax: *
E-Mail: *

Broker
Click here if not *
applicable
Name:

Not Applicable

Address Line 1:
Address Line 2: *
Address Line 3: *
City:
State:
Zip:
Contact Name: *
Phone:

https://tpccapps.exim.gov/apps/ecfs/ecfsprod.nsf/0/1ABA8340947C1CEE852572A4004D...

3/20/2007

Page 3 of 3

*
Fax: *
E-Mail: *

Issuing Bank
Click here if not
applicable
Name:

Not Applicable

Address Line 1:
Address Line 2: *
Address Line 3: *
City:
Country:
Contact Name: *
Phone: *
Fax: *
E-Mail: *

https://tpccapps.exim.gov/apps/ecfs/ecfsprod.nsf/0/1ABA8340947C1CEE852572A4004D...

3/20/2007