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

Insurance Recovery Placement Form

Type Of Assignment

Deductible Recovery Earned Premium

Claim Overpayment Audit Premium

Other Unearned Commission

Client Name Date

Assigned By Phone

Address

Responsible Party Information

Name Claim Number

Address

City, State, Zip

Phone Total Balance Owed $

Comments

Submitter's Email Address

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