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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) (Death Claim) Dear Claims Adjuster: On the occurred to day of (month/year), the loss of life (name of decedent) as a result of

(cause of death). The decedent was years of age at the time of death, and a certified copy of the death certificate is enclosed for your information and file. The above-referenced policy was in effect at the time of death. The policy of insurance, as above-referenced, was issued in the name of (name of insured) by and through your company or one of its subsidiaries identified as (name of insurer). A claim arises pursuant to said policy by virtue of the following (circle appropriate item): 1. 2. 3. 4. 5. 6. 7. 8. LIFE INSURANCE DEATH BENEFIT, WHOLE LIFE: LIFE INSURANCE DEATH BENEFIT, COMBINATION POLICY: LIFE INSURANCE DEATH BENEFIT, TERM POLICY: LIFE INSURANCE DEATH BENEFIT, GROUP POLICY: ANNUITY BENEFITS: this is a test RETIREMENT POLICY BENEFITS: THIRD PARTY CLAIM: OTHER: (Specify)

Kindly acknowledge to the undersigned receipt of this Notice of Loss, and kindly initiate file process and claim proceedings. Once confirmation of the foregoing is acknowledged by your office, a copy of the policy and details relating to the claims made thereunder may be directed to you. Additional information relating to any pending estate matters will also be provided when appropriate and upon request. Should there be any concerns which you may have relative to the coverage or the policy, kindly address those to the undersigned. Your courteous response will be most appreciated. Thank you. 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.