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ITEMS #10- #12 PERTAIN TO AUTO CLAIMS. IF THESE DO NOT APPLY, PROCEED <br />TO ITEMS #13, #14, SIGN AND DATE. <br />In order that subrogation claims may be adjudicated, it is essential that you provide the <br />following information regarding the insurance coverage of your vehicle: <br />10. Do you carry automobile insurance? Yes No <br />Give name and address of insurance company and policy number. <br />11. Have you filed a claim on your insurance carrier in this instance? <br />Yes No <br />Do you have full coverage or a deductible? <br />What is your deductible? <br />If such claim has been filed, what action has your insurer taken, or what action <br />does it propose to take with reference to your claim? (It is necessary that you ascertain <br />these facts.) <br />12. Do you carry public liability and property damage coverage? <br />Yes No <br />13. Have you reported your accident/incident to the police? <br />Yes <br />Report Number <br />Please submit report. <br />No Why? <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 YOUR <br />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 />-3- <br />