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

Subrogation Placement Form

Client Name		Date
Assigned By		Phone
Address
Policy Holder		Total Claim Amount $
Claim Number		Deductible $
State Of Loss		Property Loss $
Date Of Loss		Personal Injury $

Adverse Owner

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

Adverse Driver

Name
Address
City	State	Zip
Phone
Third Party Carrier?
Comments

Submitter's Email Address

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