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LEGALDOCS - Automobile Insurance Claim Letter Questionnaire

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Many insurance policies require the insured to formally and timely notify their carrier of any loss. Although telephonic notification may be sufficient, a written notification will provide proof that the insured complied with policy requirements. This form will complete a letter to your insurance company to make a claim for a loss you believe is covered under your automobile insurance claims policy. You will need your policy to obtain your policy number to complete this form. It is recommended that you mail this letter Certified Mail, proof of receipt required.

Use this form for a claim under an Home Owner's Insurance Policy.

To complete your Automobile Insurance Claim Letter, complete this form.

Policy Holder Information:

Insured's Name:
Insured's Street Add.:
Insured's City:
Insured's State:
Insured's ZIP:
Insured's Tel.#:

Insurance Company Information:

Insurance Company Name:
Ins. Co. Street Add.:
Ins. Co. City:
Ins. Co. State:
Ins. Co. ZIP:

Insurance Policy Information:

The Policy under which this claim is made is Policy


The automobile being insured is a:


(For example, "1995 Cadillac, VIN#xxxxxxxxxxxxx".)

Loss Information:

The date of the loss is

Describe the reason for the loss. Finish this sentence:

(For example, "an accident between the insured automobile and another vehicle at the intersection of 1st. Street and A Avenue in Boulder, Colorado", OR "a theft out of the insured automobile in the parking lot of XXXXX Department Store in Longmont, Colorado".)

Describe the loss suffered by the Insured:
Finish this sentence:

(Be specific and detailed: For example, "damage to the insured automobile and the other vehicle, and personal injuries to a passenger named XXXX and driver to the other vehicle" OR "loss of a stereo system which was factory installed at time of purchase".)

Date of Letter:

Chose the date of your Claim Letter. For example, Nov. 10, 2006.

This completes the information input for your Automobile Insurance Claim Letter. When you Send this Form, this program will prepare a Summary of the Automobile Insurance Claim Letter for your review. Make sure that all facts stated in the Summary are correct in all respects.


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