SAMPLE

Policy Holder Information:

Insurer's Name: __________

Insurer's Street Address:_________

Insurer's City: __________

Insurer's State: __________

Insurer's ZIP: __________

Insurer's Tel.#: __________

Insurance Company Information:

Insurance Company Name: __________

Insurance Company . Street Address: __________

Insurance Company City: __________

Insurance Company State: __________

Insurance Company ZIP: __________

Insurance Policy Information:

The Policy under which this claim is made is __________

The property address being insured is __________

Loss Information:

The date of the loss is __________

The loss came about as a result of __________

As a result of the reason described above, the insured suffered __________

The date of this Claim Letter is __________