T.L. THOMPSON & ASSOCIATES
P.O. BOX 496149
GARLAND, TEXAS 75049-6149
800-800-5235

You can email us if you have any trouble with this form or have any questions.

Phone: 972-226-1010
Fax: 972-681-1225

Please make sure the form is filled out completely.

 

Date:
Adverse Name:
Adverse Address:
City:
State:
Zip:
Amount of Claim:
Date of Loss:	State in which loss occured:
Insured's Name:
Claim Number:
By:
Phone Number
Comments.