Insurance Motorist Letter

INSURANCE MOTORIST LETTER

Insurer and Policy Identification

Insurer Name:

Policy Number:    Effective Period From:   To:

Insured / Motorist Information

Date of Birth:    Phone:    Email:

Policy Coverages & Limits

Applicable Coverages (check all that apply):

Liability    Limit:

Collision    Deductible:

Comprehensive    Deductible:

Uninsured/Underinsured Motorist    Limit:

Claim / Loss Details

Date of Loss:    Time of Loss:

Estimated Property Damage:    Claim Number (Insurer):

Documentation Checklist

Indicate which documents are attached or will be provided to support this Motorist Letter:

Police report

Photographs of damage/scene

Repair estimate(s)

Medical records / bills

Witness statements

Exclusions and Reservation of Rights

The following exclusions, limitations and reservations apply to any statement or acknowledgement contained in this Motorist Letter: coverage remains subject to all policy terms, conditions, endorsements, and exclusions. This letter is provided for information only and shall not be construed as an admission of liability or a waiver of any right of subrogation, deductible, or coverage defense.

No policy exclusions known to issuer that would bar payment for the described loss

Payee / Beneficiary for Settlement (if applicable)

Payee Name:

Relationship to Insured:    Percent of Proceeds:

Declaration, Consent and Certification

I certify that the information provided in this Motorist Letter is true, complete and accurate to the best of my knowledge. I understand that any material misrepresentation or omission may constitute insurance fraud. I authorize the insurer and its authorized representatives to investigate the facts, circumstances and legal liability related to the reported loss and to obtain records, statements and other information relevant to claim handling and subrogation.

I acknowledge that this Motorist Letter does not constitute a guarantee of payment, admission of liability or modification of policy terms. The insurer reserves all rights under the policy, including but not limited to the right to deny coverage or pursue subrogation against responsible third parties.

Consent to Subrogation: I consent to the insurer's pursuit of subrogation and assignment of rights as necessary to recover payments made in connection with this loss.

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