CLAIM NOTICE – POLICYHOLDER

To: Claims Department, [CARRIER NAME / EMAIL / ADDRESS]
From: [INSURED NAME] / Policyholder
Policy No(s).: [POLICY NUMBER(S)] (Line: [P&C/EPLI/D&O])
Date: [DATE]

1. NOTICE OF CLAIM / CIRCUMSTANCE

• Type: [Claim / Circumstance Notice].
• Incident/Claim date: [DATE]; Location: [LOCATION].
• Parties involved/Claimant(s): [NAMES].
• Description: [Brief factual summary; alleged wrongful acts; property damage; employment practice allegations; securities demand].

2. POLICY AND COVERAGE TRIGGER

• Policy Period: [START DATE] to [END DATE].
• Retroactive Date (if claims-made): [DATE or N/A].
• Trigger: [Claim first made on DATE within policy period / Occurrence within policy period / Wrongful act after retro date].
• Related claims/circumstances previously reported: [None / Describe and dates].
• Excess/umbrella carriers noticed concurrently: [List or N/A].
• Policy section for notice: [cite Section, e.g., IV.A Notice of Claim].

2. REQUESTED COVERAGE

• Defense: Appoint counsel per policy or consent to insured’s choice: [COUNSEL NAME/FIRM].
• Indemnity: Coverage for damages/settlement/judgment.
• Advancement of defense costs (if applicable): [Yes/No].
• Coverage enhancements/riders invoked: [List if applicable].

3. TIMELINESS AND COOPERATION

• Notice provided promptly pursuant to policy conditions.
• Insured will cooperate and provide additional information reasonably requested.

4. PRESERVATION

• Please confirm claim number and adjuster assignment.
• Preserve all communications regarding coverage decisions.
• Please provide a written coverage position within [30] days.
• If represented on coverage, direct correspondence to: [COVERAGE COUNSEL NAME/EMAIL].

5. RESERVATION OF RIGHTS (INSURED)

• Insured reserves all rights and defenses under the policy and law. No statements herein waive any rights.

6. ATTACHMENTS

• [Complaint/Demand Letter/EEOC Charge/SEC Letter]
• [Incident report/photos/board minutes]
• [Loss estimates/resumes of key personnel/contact list]

7. NOTICE DELIVERY

• This notice sent via [certified mail RRR / email per Policy Section X / carrier portal] on [DATE].

Signed:
[NAME/TITLE]
[INSURED ENTITY]
[CONTACT INFO]