Notice of Insurance Claim
Date: ____________________
_________________________
_________________________
_________________________
[name and address of insurance company]
Name of your insured: _________________________
Policy number: _______________________________
To Whom It May Concern:
Please be advised that  [   ]  I received injuries  [   ]  I sustained property damage in an accident on _______________ at the following location: _________________. The accident involved:
[   ]	two or more motor vehicles
[   ]	motor vehicle and pedestrian
[   ]	motor vehicle and bicycle
[   ]	motor vehicle and property
[for all motor vehicles involved other than your own, give]:
Make, model, year, and color of vehicle: ______________________________
License plate number and state of issuance: __________________________
Vehicle identification number: ______________________________________
Name of driver (if different from name of insured above): ____________________
Driver's license number and state of issuance: _____________________________
[   ]	slip and fall
[   ]	animal bite, claw, knockdown, etc.
[   ]	dangerous or defective product
[   ]	other (specify): _________________________
The person named above was involved in the incident. Please confirm in writing to the address below your liability coverage of the insured identified above. Please also advise whether your insured contends that anyone other than your insured may be in whole or in part legally responsible for accidents on or near the premises or for this accident.
As requested, please respond in writing. If necessary, I may be reached by telephone at the below number.
Thank you for your prompt attention to this matter.
Sincerely,

_____________________________________________ Date: _______________
Signature

___________________________________________________
Name

___________________________________________________
Address

___________________________________________________
Phone