Representation Letter to Insurance Company

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This Representation Letter to Insurance Company is from an attorney to client's auto insurance company informing them of representation. It also requests information regarding the limits under the client's insurance policy.

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This Representation Letter to Insurance Company is formal notice from an attorney to an insurance company regarding representation of a client who was involved in an auto accident. This letter requests confirmation that the client has medical payment benefits as well as uninsured/underinsured motorist coverage. A HIPPA Authorization signed by the client will also be included with this representation letter.

This Representation Letter to Insurance Company includes:
  • Parties: Sets forth the name of the client, date of loss and claim number (if applicable);
  • Confirmation: Sets forth a request for confirmation of policy limits for both insured and uninsured motorist coverage under the client's policy;
  • Authorization: Encloses an authorization signed by the client which allows the insurance company to provide the necessary information.

Protect yourself and your rights by using our attorney-prepared orms.

This attorney-prepared packet contains:
  1. General Information
  2. Representation Letter to Insurance Company
State Law Compliance: This form complies with the laws of all states
Number of Pages2
DimensionsDesigned for Letter Size (8.5" x 11")
EditableYes (.doc, .wpd and .rtf)
UsageUnlimited number of prints
Product number#28072
This is the content of the form and is provided for your convenience. It is not necessarily what the actual form looks like and does not include the information, instructions and other materials that come with the form you would purchase. An actual sample can also be viewed by clicking on the "Sample Form" near the top left of this page.


[Insurance Company]
[Insurance Company Address]
Attn: Claims Department
Re:    Our Client: XXX
         Your Insured:  XXX
         Date of Loss:   ______________
         Claim #: _________________________
Dear Sir/Madam:
This letter will confirm that this law office has been retained by XXX with reference to injuries she sustained in a motor vehicle accident on the above-mentioned date.  We  request that you confirm our client has medical payments benefits and uninsured/underinsured motorist coverage through the policy issued by your company, and the limits on each.  If she does not have either or both of these, please forward the application showing the signed rejection of coverage.  It would also be appreciated if you would please advise me of the claim number for this incident.
As I am sure you are aware, all communications regarding this incident must be made through this office.  I am also enclosing an Authorization HIPPA signed by our client so you can release this information to me.   
Thank you for your time and consideration in this matter.    Please feel free to contact the undersigned should you have any questions pertaining to this correspondence.
cc:   _________________________
Enclosures as stated
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