NOTE TO PRACTITIONER
This template is provided for general informational purposes only and does not constitute legal advice. Use of this template does not create an attorney–client relationship. You should tailor all provisions to the facts, applicable law, and strategic objectives of the matter at hand. Consult competent counsel admitted in the relevant jurisdiction before relying on or filing this document.

FORMAL DEMAND FOR PAYMENT UNDER INSURANCE POLICY

(Comprehensive Demand Letter Template)

TABLE OF CONTENTS

I. Document Header
II. Definitions
III. Operative Provisions
IV. Representations & Warranties
V. Covenants & Restrictions
VI. Default & Remedies
VII. Risk Allocation
VIII. Dispute Resolution
IX. General Provisions
X. Execution Block

I. DOCUMENT HEADER

[DATE]

Via [CERTIFIED MAIL / COURIER / ELECTRONIC DELIVERY]
Return-Receipt Requested

[INSURANCE COMPANY NAME]
Attn: [CLAIMS ADJUSTER NAME / LEGAL DEPARTMENT]
[STREET ADDRESS]
[CITY, STATE ZIP]

Re: Formal Demand for Payment Under Policy No. [POLICY NUMBER]
Claim No. [CLAIM NUMBER] | Date of Loss: [DATE OF LOSS] | Insured: [INSURED NAME]

Dear [MR./MS.] [ADJUSTER LAST NAME]:

This Formal Demand for Payment (the “Demand Letter” or “Letter”) is issued on behalf of [CLAIMANT NAME] (“Claimant”) to [INSURANCE COMPANY NAME] (“Insurer”) pursuant to applicable state insurance law (“Governing Law”) and the terms and conditions of the above-referenced insurance policy (the “Policy”). Claimant hereby demands prompt payment of covered losses, up to and including the Policy Limits, together with all ancillary amounts legally recoverable.

II. DEFINITIONS

For ease of reference, the following capitalized terms have the meanings set forth below and shall apply throughout this Letter:

“Claim” means the loss event(s) occurring on or about [DATE OF LOSS] giving rise to coverage under the Policy.

“Damages” means all economic and noneconomic losses, including but not limited to medical expenses, lost wages, property damage, pain and suffering, and any other compensable harm in accordance with Governing Law.

“Demand Amount” means the total sum specified in Section III.2, which shall not exceed the Policy Limits.

“Policy Limits” means the maximum indemnity available under the Policy for the Claim. [PLACEHOLDER: Insert specific dollar amount if known.]

III. OPERATIVE PROVISIONS

1. Basis of Liability
   1.1 Insured’s Liability: The evidence summarized in Exhibit A and detailed in the enclosed supporting documentation establishes the Insured’s clear legal responsibility for Claimant’s Damages.
   1.2 Coverage Trigger: The Claim constitutes an “occurrence” and/or “covered loss” under the Policy, thereby obligating Insurer to indemnify or pay on behalf of the Insured.

2. Demand for Payment
   Claimant hereby demands payment in the amount of [DEMAND AMOUNT] inclusive of all special, general, and consequential Damages, together with any applicable prejudgment interest, costs, and statutory enhancements as permitted by Governing Law. This Demand Amount is expressly limited to, and without waiver of, Claimant’s right to recover the full Policy Limits.

3. Conditions Precedent
   3.1 Compliance: Claimant has satisfied all contractually or statutorily required conditions precedent to payment, including notice of loss, cooperation in the investigation, and provision of medical and financial records.
   3.2 Cure Period: Insurer shall remit full payment of the Demand Amount within [30] calendar days of receipt of this Letter (the “Cure Period”).

4. Manner of Payment
   Payment shall be made by wire transfer or certified funds payable to “[LAW FIRM TRUST ACCOUNT / CLAIMANT],” delivered to the address in Section I or as otherwise directed in writing.

[// GUIDANCE: Adjust deadlines to comply with any statutory “time-limit demand” provisions in the governing jurisdiction. Consider attaching an itemized damages spreadsheet for clarity.]

IV. REPRESENTATIONS & WARRANTIES

1. Claimant represents that all statements, medical records, invoices, and other materials provided in support of the Claim are true, accurate, and complete to the best of Claimant’s knowledge.

2. Claimant further represents that no other insurer or third party holds subrogation rights inconsistent with this Demand, except as disclosed in Exhibit B.

3. These representations shall survive Insurer’s payment and any settlement agreement executed in connection herewith.

V. COVENANTS & RESTRICTIONS

1. Claimant agrees to execute a mutually acceptable release of the Insured upon receipt and clearance of the Demand Amount, limited to the Claim and conditioned on payment of all sums due.

2. Claimant shall refrain from initiating litigation against the Insured or Insurer during the Cure Period provided Insurer acts in good faith to resolve the Claim.

3. Claimant will provide reasonable, timely updates of any material developments affecting Damages.

VI. DEFAULT & REMEDIES

1. Events of Default
   Failure by Insurer to (a) remit the Demand Amount in full within the Cure Period, (b) communicate a written, good-faith settlement response within [15] days, or (c) otherwise comply with statutory duties of good-faith claims handling, shall constitute an Event of Default.

2. Remedies
   Upon an Event of Default, Claimant may, without further notice:
   a. File suit against the Insured and/or Insurer seeking full tort Damages and all available legal and equitable relief;
   b. Pursue statutory bad-faith remedies, including extracontractual and punitive damages;
   c. Seek recovery of attorney fees, expert costs, and prejudgment interest as permitted by Governing Law.

3. Notice of Litigation Hold
   Insurer is hereby placed on notice to preserve all documents, electronic communications, and claims files pertaining to the Claim, commencing on the date of this Letter.

VII. RISK ALLOCATION

1. Limitation of Liability
   Claimant’s monetary demand is limited to the Policy Limits for purposes of this settlement offer; however, such limitation is withdrawn automatically upon an Event of Default.

2. No Admission
   Nothing herein shall be construed as an admission of liability by Claimant.

3. Force Majeure
   Performance deadlines shall be extended for force-majeure events beyond the reasonable control of the affected party, provided prompt written notice is given.

VIII. DISPUTE RESOLUTION

1. Governing Law
   This Demand Letter and any settlement arising herefrom shall be governed by the laws of the state referenced in Section I (“Governing Law”), without regard to conflict-of-laws rules.

2. Forum Selection
   In the event litigation becomes necessary, venue shall be proper in any court of competent jurisdiction located in [COUNTY, STATE].

3. Arbitration & Jury Waiver
   Not applicable unless expressly agreed to in a subsequently executed settlement agreement.

IX. GENERAL PROVISIONS

1. Amendment & Waiver
   No amendment or waiver of any provision of this Letter shall be effective unless in writing and signed by both Claimant and Insurer.

2. Assignment
   Neither party may assign rights or delegate obligations arising under this Letter without the prior written consent of the other party, except as required by law.

3. Severability
   If any provision of this Letter is held unenforceable, the remaining provisions shall remain in full force and effect to the broadest extent permitted by law.

4. Entire Agreement
   This Letter constitutes the entire demand and supersedes all prior oral or written communications regarding the Claim, except for documents expressly incorporated by reference.

5. Counterparts; Electronic Signatures
   This Letter may be executed in counterparts, each of which shall be deemed an original. Signatures transmitted via PDF, facsimile, or secure electronic signature platform shall be deemed valid and binding.

X. EXECUTION BLOCK

IN WITNESS WHEREOF, the undersigned has executed this Demand Letter as of the date first written above.

[CLAIMANT NAME]
By: _______
Name: [AUTHORIZED SIGNATORY]
Title/Capacity: [INDIVIDUAL / ATTORNEY-IN-FACT / LEGAL REPRESENTATIVE]
Address: [STREET, CITY, STATE ZIP]
Email: [EMAIL ADDRESS]
Phone: [PHONE NUMBER]

cc: [INSURED NAME]
Enclosures:
• Exhibit A – Liability & Damages Summary
• Exhibit B – Subrogation/Third-Party Interests
• Exhibit C – Supporting Medical Records & Bills
• Exhibit D – Photographs / Incident Reports

[// GUIDANCE: Attach only those enclosures necessary to substantiate each category of Damages and preserve privileged work product separately.]

OPTIONAL NOTARIZATION

State of _ )
County of ______ ) ss.

Subscribed and sworn before me this ___ day of _, 20_, by ________.

Notary Public
My Commission Expires: _______

[// GUIDANCE: Verify notarization and witness requirements under the Governing Law before inclusion.]

END OF TEMPLATE