INSURANCE CLAIM NOTICE

Date :

To _______________

   _______________

   _______________

Dear _______________

You are hereby notified that I have incurred a loss which I believe is covered by my insurance policy detailed below. Details of the loss are as follows:

1. Type of loss or claim: _______________
2. Date and time incurred: _______________ _______________
3. Location: _______________
4. Estimated loss: _______________

Please forward a claim form to me as soon a possible.

Yours sincerely

Home Phone _______________

Work Phone _______________

Policy Number _______________