Notice of Insurance Claim
Date: 	
To: 	

	
[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 
	[date], at approximately 	 [time], at the following location:
		 [place].
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): 	
Your insured 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 number below.
Thank you for your prompt attention to this matter.
Sincerely,
Signature 	 Date 	
Printed name 	
Address 	
Email 	 Phone