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Date:

To: (Insurance Company)
Claims Department
Address / Email:

RE: Notice of Claim
Your Insured (Carrier):
USDOT #: MC #:
Policy #:
Claim # (if assigned):

Dear Claims Representative,

This letter is notice of a claim arising from a motor vehicle accident involving your insured's commercial vehicle.

Date/time of accident:
Location:
Police agency & report #:
Your insured's driver: Truck/Trailer #:

Brief description:

Damages/losses being claimed (attach documentation):

Enclosed: ☐ Police report ☐ Photos ☐ Repair estimate(s) ☐ Towing/storage invoices ☐ Other:

Please acknowledge receipt, assign a claim number and adjuster, and contact me at the information below.

Sincerely,

Name:
Company:
Phone: Email:
My insurer & claim # (if any):