TGA

THOMAS GEORGE ASSOCIATES
Insurance Recovery Division
P.O. Box 30 / 10 Larkfield Road E. Northport, NY 11731
Phone (631) 261-8800 / Fax (631) 261-8896

Arbitration Placement Form

Assigned By		Phone
Date		Total Claim Amount $
Insured Name		Deductible $
Claim Number		Property Damage $
Loss Location		PIP / NFMP $
Date of Loss		Rental $
Insured Vehicle		Salvage $
Last Offer ?		Towing/Storage $

Adverse Party

Name
Address
City	State	Zip
Phone
Year and Make of Car/License Plate

Third Party Carrier Info

Name
Address
City	State	Zip
Phone
Claim Number
Claim Rep
Submitter's Email Address
Comments

Submitter's Email Address

E-MAIL us at TGACOL@tgaltd.com or call 1-800-443-8338