Fill and Sign the Insurance Claim Accident Form

Notice of Insurance Claim on the Policy of Another due to Motor Vehicle Accident _______________________ (Date) _________________________________ (Name of Insurance Company or Agent) ___________________________________________________ (P. O Box or Street Address, City, State, Zip Code) Re: ___________________; Policy Number ___________________ (Name of Insured) To Whom It May Concern: Please be advised that the undersigned ____________________ (Name) received injuries and sustained property damage in an accident on ________________ (date) , at the following location: (describe) __________________________________ ______________________________________________________________________ _____________________________________________________________________ . The accident involved: (The following are examples of different alternatives). [ ] two or more motor vehicles. [ ] motor vehicle and pedestrian [ ] motor vehicle and bicycle [ ] motor vehicle and property The following is a description of all vehicles involved (other than vehicle of the insured):  Make, model, year, and color of vehicle: ____________________________  License plate number and state of issuance: __________________________  Vehicle identification number: _____________________________________  Name of driver ______________________  Driver's license number and state of issuance: _____________ The person named above in this Notice _________________ (Name of Person) , is insured by your Company and was involved in the incident. Please confirm in writing to the undersigned at ____________________________________________________ ____________________ (P. O Box or Street Address, City, State, Zip Code) 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 the accident on or near the location described above. As requested, please respond in writing. If necessary, I may be reached by telephone at _________________ (phone number) . Thank you for your prompt attention to this matter. Sincerely, _______________________________ (Printed Name) ______________________________ (Signature)