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Back to Forms for 'Agency'.




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: _________________




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



Name: _______________________________________________________________

Address: _____________________________________________________________

Telephone: _________________________________________



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