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PROOF OF LOSS FOR <br />CLAIM FOR DAMAGE OR INJURY* <br />(Attach additional sheets if necessary) <br />Name of Claimant (please provide full name) <br />2. Address of Claimant (street, city, state, zip code) <br />Mailing Address of Claimant (if different from above address) <br />3. Telephone Numbers: (residence) (business) <br />4. Date and Time of Accident: <br />Location of Accident: <br />5. Amount of Claim: Property Damage $ <br />Personal Injury $ <br />TOTAL $ <br />6. Description of Accident (Detail known facts and circumstances about the damage or <br />injury. Identify persons and property involved and the cause thereof. Use additional <br />sheets of paper if required.) <br />*PLEASE BE ADVISED THAT FILING OF YOUR CLAIM WITH THIS OFFICE DOES NOT FULFILL YOUR NEED TO <br />FILE A LAWSUIT IF YOU DISAGREE WITH THE DECISION ON YOUR CLAIM, REGARDLESS OF WHETHER <br />YOUR CLAIM IS TIMELY INVESTIGATED AND A REPLY MADE TO YOU WITHIN THE APPLICABLE PERIOD OF <br />LIMITATIONS WHICH MAY BE AS SHORT AS TWO YEARS. <br />7/10 <br />