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(Date of Letter)

(Insurance Company Name) (Claims Department) (Street Address) (City, State and Zip Code) RE: (Name of Insured) (Claim Number) (Date of Loss) (General Loss) Dear Claims Adjuster: Recently this office was contacted by (name of insured) relative to a casualty loss which occurred on the day of (month/year). Coverage for this loss is included as a part of the above-referenced policy for which premiums have been paid on a current basis. The casualty loss relating to this occurrence and policy includes the following: (Circle appropriate item(s) below.) 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. PROPERTY DAMAGE: BODILY INJURY: MEDICAL PAY: PERSONAL INJURY-DYSFUNCTION: PERSONAL INJURY-DISABILITY: PERSONAL INJURY-PAIN AND SUFFERING: WAGE LOSS: LOSS OF FUTURE EARNING CAPACITY: DEATH: LOSS OF CONSORTIUM: UNINSURED MOTORIST: UNDERINSURED MOTORIST:

13. 14. 15.

UMBRELLA OR EXCESS COVERAGE: SUBROGATION: OTHER: (Specify)

This correspondence should serve as Notice relative to the loss sustained by the insured and/or members of the insured's family on the day of (month/year), in conjunction with the item(s) noted above. Please initiate appropriate processing of this claim as a new file, if a file has not previously been activated. In addition to the foregoing, it is requested that an appropriate and immediate investigation of this loss be conducted by your office and that the undersigned be provided copies of all materials collected, pursuant to said investigation. Also, please verify the status of the policy as above-referenced and confirm the policy number to the undersigned. In that process, please confirm the coverage rates and provide the undersigned with a dec (declaration) sheet confirming policy coverage in this case. Kindly provide the undersigned with a complete copy of the applicable policy as above-referenced and acknowledge receipt of this communiqué. Should your office need any additional information from the undersigned, please advise. Thank you for your kind attention to this matter. Very truly yours,

(Signature) (Address) (City, State and Zip Code) (Phone Number) LAWCHEK, LTD. LETTER PRO Samples, Copyright 2000 This is not a substitute for legal advice. An attorney must be consulted.