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Sample Letter of Representation Insurance Company – At-Fault Carrier

{Today’s Date}

Sent via facsimile: {(xxx) xxx-xxxx}

{Adjuster’s Name and Title}
{Insurance Company Name}
{Address – Line 1}
{Address – Line 2}
{City, State, Zip}

Re:           Our Client:      {Claimant’s Name}
                  Claim No:      {}
                  Policy No:       {}
                  Insured:           {Insured’s Name}
                  Date of Loss:  {}

Dear {Adjuster’s Name}:

Please be advised that this office has been retained to represent {claimant’s name} in a claim against your insured for injuries and damages as a result of an accident that occurred in {insert city and state} on the above-referenced date.

Any and all correspondence should be made directly with this office and we ask that you refrain from any direct contact with our client.  In addition, any and all medical authorizations or releases given to your company are hereby expressly revoked.

Please forward copies of any and all written statements, incident reports, recordings, photographs and any other documents contained in your file pertaining to accident.

As a result of this accident, {claimant’s name} sustained injuries and is currently receiving accident related medical treatment. As such, we will provide you with periodic updates on {his/her} medical status so that you may set your reserves.

We look forward to working with you to resolve this matter.



{attorney’s name}

Arizona Personal Injury Complaints

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Disclaimer: The information and forms on this site are for illustrative purposes only. The information is not intended to be used by anyone other than a licensed Arizona attorney familiar with Arizona personal injury law. The forms and the information contained in them may not be up-to-date and must be independently reviewed, cite checked, rule checked, and otherwise verified by a licensed Arizona attorney. The information contained in the forms on this website cannot and must be relied on for the purposes of filing legal documents or otherwise pursuing a claim. If you have any questions about this, please contract and attorney at or by calling 602-833-1274.