NOTE: This letter is a sample that must be customized to fit the facts of your individual situation and claim. All bracketed and underlined portions must be completed or revised before sending. Use this notarized letter to inform your insurance company of your policy status.

Claim Number: ___________________

Policy Information Request
[Please check one of the boxes below]

I have no other insurance policy, other than the policy with ______________ Company issued to ___________________________ under Policy # _______________________.

In addition to the policy with ________________ Insurance Company issued to ___________________________________________, I also have the following insurance coverage(s):

Name of other insurer: ____________________________________________________
Coverage(s): ____________________________________________________
Policy Number(s): ____________________________________________________
Insurer’s Address: ____________________________________________________
Name of other insurer: ____________________________________________________
Coverage(s): ____________________________________________________
Policy Number(s): ____________________________________________________
Insurer’s Address: ____________________________________________________

[Please also check one of the boxes below]

I was NOT acting within the course and scope of any employment (i.e. working) nor was I participating in any joint venture at time of this loss.

At the time of this loss, I was acting in the course and scope of my employment and/or participating in a joint venture on behalf of the following:

Name of employer / joint-venturer: ____________________________________________
Address: _________________________________________________________________
Telephone Number: ________________________________________________________
Contact Person: ____________________________________________________________
Other Insurance (if known): __________________________________________________

Under penalties of perjury, I declare that I have read the foregoing document and that the facts stated in it are true.

I, _____________________________________, hereby swear or affirm, under oath and penalty of perjury, that the contents of this document are true and correct.

Signature: __________________________________________

Print Name: _________________________________________

Sworn to (or affirmed) and subscribed before me this __ day of _____________, 20__, by _________________________, personally known to me or who produced _________________________ as identification.

_____________________________________
(Signature of Notary Public)
______________________________
(Print, Type of Stamp Commissioned)
Name of Notary Pub