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Adjuster up-date Form
*denotes required fields
Lead insurer
Lead insurer ref
Adjuster ref
Adjuster in charge
Date of incident dd/mm/yyyy
Description of incident
Cause of incident
Description of loss/damage
Name of third party
Name of injured worker(s)
Gross reserve
Date of Immediate Advice dd/mm/yyyy
Date of Preliminary Report dd/mm/yyyy
Date of Interim Report dd/mm/yyyy
Date of Final Report dd/mm/yyyy
Claim amount
Adjusted claim
Deductible
Payment on account
Net settlement
Date claim paid dd/mm/yyyy
Fees