Notice Of Tort Claim (Page 6 of 8) in pdf

Notice Of Tort Claim Page 6

Have you made a claim against anyone else for any of the losses or expenses

claimed in this notice? _____________________________________________________

If yes, set forth the name and address of all person and insurance companies against

whom you have made such claims.

Are any of the losses or expenses claimed herein covered by any policy of

insurance?________________________________________________________________

For each such policy, state the name and address of the insurance company, policy

number and benefits paid or payable.

8. a. If this claim involves an automobile, please state:

(1) The name of the insurance company covering the automobile.

(2) The name of your local agent.__________________________________________

(3) Your policy number and dates of coverage (if other than auto).

b. (1) State the name of your Homeowners’, rental or property insurance company

(2) The name of your local insurance agent. _________________________________

(3) Your policy number. _________________________________________________

If you have any other form or kind of insurance, please state:

(1) The name or names of the insurance company.

(2) Type of liability coverage. _________________________________________

(3) The name of your local agent. ______________________________________

(4) The policy number or numbers. _____________________________________

Have you received or agreed to receive, any money from anyone for the

Notice Of Tort Claim Page 6