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LEGALDOCS - Homeowner's 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 home 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 Automobile Insurance Policy.

To complete your Homeowner's 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 property address being insured is

Loss Information:

The date of the loss is

Describe the reason for the loss. Finish this sentence:

(For example, "a home burglary on the Loss Date described above", OR "storm and resulting water damage from a storm on the Loss Date described above" OR "a fire which started on the Loss Date described above".)

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

(Be specific and detailed: For example, "the loss of jewelry consisting of XXXXX, believed to have a value of $3,000, a television with a value of $500, and damage to the home which will cost $1,000 to repair" or "loss to the entire upper story of the home to fire and water damage, the repair cost of which is presently unknown".)

Date of Letter:

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

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


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