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 _______________