2 3 PRIOR CARRIER INFORMATION / LOSS HISTORY PROVIDE INFORMATION FOR THE PASTS YEARS AND USE THE REMARKS SECTION FOR LOSS DETAILS I I LOSS RUN ATTAOEO YEAR CARRIER & POLICY NUMBER ACTUAUAUMTTOPREIMMI MOD I CLAMS AMOUNT PAID RESERVE CO Pa. It CO Pa. FI: OD. POT. N: CO: ROL I: CO POL