7378 W. Atlantic Blvd. # 142Margate, Florida. 33063Phone 954 975-0210Lic: A9800001 Service Request Form. Date Received: Adjuster: Company: E-Mail: Phone # Claim # File # Case: Attorney: Law Firm: Claimant: Telephone: Address: Unit/Apt # City: State: Zip: Dob: Years Old. SSN (Last 4 Only): DL # (First 3 Only): Race:Select RaceWhiteBlack or African AmericanAmerican Indian or Alaska NativeAsianHispanic or LatinoNative Hawaiian or Other Pacific Islander Sex:Select SexMaleFemaleNon-BinaryTransgenderI Prefer Not To Say Height (Feet): Height (Inches): Weight: Hair: Glasses:Select GlassesYesNo Employer: Employer Address: Date of Loss: Injury: Limitations: Instructions: Vehicle (Year, Make, Model and Color): Vehicle (Year, Make, Model and Color): Vehicle (Year, Make, Model and Color):