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Back to Forms for 'Agency'.


ACCIDENT CLAIM NOTICE

ACCIDENT CLAIM NOTICE

 

Date: ________________

 

To: __________________

 

 

You are hereby notified of a claim filed against you for damages arising from the following accident or injury for which, in my opinion, you and / or your agents are liable.

 

Description of Accident: _______________________________________________

____________________________________________________________________

____________________________________________________________________

 

Date: _________________

 

Time: _________________

 

Location:____________________________________________________________

 

Please have your insurance representative or attorney contact me as soon as possible.

 

 

Name: _______________________________________________________________

Address: _____________________________________________________________

Telephone: _________________________________________

 

 



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