INSURANCE CLAIM NOTICE

 

Date:  ________________________

 

To:  _________________________

       _________________________

       _________________________

       _________________________

 

You are hereby notified that we have incurred a loss covered by insurance you underwrite.  The claim information is as follows:

 

1.   Type of Loss or Claim:

______________________________________________________________________

______________________________________________________________________

2.   Date and Time Incurred:

______________________________________________________________________

______________________________________________________________________

3.   Location:

______________________________________________________________________

______________________________________________________________________

4.   Estimated Loss or Casualty:

______________________________________________________________________

______________________________________________________________________

 

Please forward a claim form or have an adjuster call me at the telephone number below.

 

________________________________________                          _______________

Signature                                                                                            Date

 

Policy Number: ___________________________________

 

Print Name __________________________________________

 

Address ________________________________________

 

Telephone No. (Work) ____________________________

 

Telephone No. (Home) ____________________________