Sample Letter Form Notifying Insurer Of Claim Or Incident
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1Sample Letter Notifying Insurer
of Claim or Incident
<DATE>
Brokers “R” Us
123 S. Main Street
Anywhere, USA
RE:
Notice of Accident:
(
) Insurance Company
Claimant:
Mary Jo Fell
Your Insured:
XYZ Construction
Job:
Construction of ABC Development
Date of Incident:
February 29, 2003
Dear Broker:
Your office has previously issued an endorsement for the above captioned work being conducted
by your insured at our ABC Development. Enclosed you will find an incident report, which
appears to have been caused by your insured’s work.
The above referenced endorsement names our Housing Authority as an Additional Insured. We
hereby request defense and indemnity pursuant to our insurance endorsement and rights under
your insurance policy no.: ________________________.
Please have your adjuster contact me so that we can assist him/her in the investigation. I can be
reached at the telephone number shown above/below.
Sincerely,
Executive Director
cc: Contractor
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