Sample notice of claim

• Author: Scott M. Riemer/Jennifer L. Hess
• Pages: 210-210

Form 2 ERISA Disability Claims and Litigation A-192

FORM 2 SAMPLE NOTICE OF CLAIM

DATE

VIA FAX AND MAIL

Insurer Address

Re: Client

Name

Claim #,

etc:

Dear Sir or Madam:

We hereby submit Notice of Claim in accordance with the requirements of

the above-referenced policy. Client has been totally/partially disabled and unable

to work as of DATE. Please furnish us with copies of all the relevant claims forms





in regard to CLIENT are enclosed.



Sincerely yours,