Notice of Insurance Claim

If you’re planning to make a claim against an insurance company—because you were in a car accident, suffered a slip and fall or animal bite, or have any other type of claim—you can use this Notice of Insurance Claim to notify the appropriate insurance company or companies.

You can save and edit the form before you buy--just create a Nolo.com account. It's easy, free, and there's no obligation to buy anything. If you purchase the form, you'll be able to print, send, or download it.

See below for full product details.



Name of insured: 
Policy number: 

 

To Whom It May Concern:

Please be advised that an accident occurred on  at the following location: .

Alternate Selection
Label  
property damage only
Alternate Selection
Label Contract Text
vehicular accident
Alternate Selection
Label Contract Text
two or more vehicles

As a result of this accident I sustained property damage. The damages were the result of a vehicle accident that involved two or more motor vehicles.

pedestrian

As a result of this accident I sustained property damage. The damages were the result of a vehicle accident involving a motor vehicle and pedestrian.

bicycle

As a result of this accident I sustained property damage. The damages were the result of a vehicle accident involving a motor vehicle and a bicycle.

property

As a result of this accident I sustained property damage. The damages were the result of a vehicle accident involving a motor vehicle and property.

other

As a result of this accident I sustained property damage. The damages were the result of the following: .

Multiple Selection
Label Contract Text
vehicle information Additional information regarding the vehicle(s) includes the following:

Multiple Selection
Label Contract Text
model and make

Make, model, year, and color of vehicle: 

license plate

License plate number and state of issuance: 

VIN

Vehicle identification number: 

DL Number

Driver's license number and state of issuance: 

driver

Name of driver: 

slip and fall

The damages were the result of a slip and fall.

animal bite

The damages were the result of an animal bite.

dangerous/defective product

The damages were the result of a dangerous or defective product.

other

personal injury only As a result of this accident I received injuries.
property damage and injury
Alternate Selection
Label Contract Text
vehicular accident
Alternate Selection
Label Contract Text
two or more vehicles

As a result of this accident I sustained property damage and received injuries. The damages were the result of a vehicle accident that involved two or more motor vehicles.

pedestrian

As a result of this accident I sustained property damage and received injuries. The damages were the result of a vehicle accident involving a motor vehicle and pedestrian.

bicycle

As a result of this accident I sustained property damage and received injuries. The damages were the result of a vehicle accident involving a motor vehicle and a bicycle.

property

As a result of this accident I sustained property damage and received injuries. The damages were the result of a vehicle accident involving a motor vehicle and property.

other

As a result of this accident I sustained property damage and received injuries. The damages were the result of the following: .

Multiple Selection
Label Contract Text
vehicle information Additional information regarding the vehicle(s) includes the following:

Multiple Selection
Label Contract Text
model and make

Make, model, year, and color of vehicle: 

license plate

License plate number and state of issuance: 

VIN

Vehicle identification number: 

DL Number

Driver's license number and state of issuance: 

driver

Name of driver: 

slip and fall

The damages and injuries were the result of a slip and fall.

animal bite

The damages and injuries were the result of an animal bite.

dangerous/defective product

The damages and injuries were the result of a dangerous or defective product.

other

The person named above (Name of Insured) was involved in the incident. Please confirm in writing to the address below your liability coverage of the insured identified above. Please also advise whether your insured contends that anyone other than your insured may be in whole or in part legally responsible for accidents on or near the accident site or premises, or for this accident.

If necessary, I may be reached by telephone at the number below. Thank you for your prompt attention to this matter.

Keep Together

Sincerely,

_________________________________________



 

Loading your form ...

1-Year Subscription

Price: $30

You May Also Like