RE: <<Cli_First>> <<Cli_Last>> Company: <<Pol_Company:PC>> Policy Number: <<Pol_PolNum>>

en español a continuación

PLEASE WRITE BELOW THE REQUESTED INFORMATION REGARDING YOUR INSURANCE. IF YOU DO NOT HAVE INSURANCE, PLEASE SIGN THE SECTION CALLED "UNINSURED MOTORIST". PLEASE RETURN THIS LETTER IN THE ENCLOSED ENVELOPE. A COPY OF THIS LETTER IS ENCLOSED FOR YOUR RECORDS. IF YOU HAVE ANY QUESTIONS, PLEASE DO NOT HESITATE TO CALL US.

==== FAVOR ESCRIBA EN LA INFORMACIÓN SOLICITADA EN RELACIÓN CON SU SEGURO. SI USTED NO TIENE SEGURO, POR FAVOR FIRME la sección llamada "motorista sin seguro". FAVOR DE REGRESAR ESTA CARTA EN EL SOBRE ADJUNTO. UNA COPIA DE ESTA CARTA SE ADJUNTA PARA SU ARCHIVO. SI TIENE ALGUNA PREGUNTA, POR FAVOR NO DUDE EN LLAMAR EE.UU..

Sincerely,

<<User Name>>
<<Agncy_Name>>
<<Agncy_Address>>, <<Agncy_City>>, <<Agncy_State>>  <<Agncy_Zip>>
Phone:<<Agncy_Phone>>  |  Fax: <<Agncy_Fax>>

NAME OF INSURANCE COMPANY: ________________________________________

POLICY NUMBER: _____________________________________________________

NAME OF YOUR AGENT: _______________________________________________

AGENT'S ADDRESS: _______________________________________________________

                                                     Street                 City                     Zip code

AGENT'S PHONE: (      ) ____________            YOUR PHONE: (     ) ______________

_______________________________ DATE:_____________________

Your signature

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UNINSURED MOTORIST: [No tenia seguro en el momento del accidente.]

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I HAD NO INSURANCE AT THE TIME OF THE ACCIDENT.

<<Input:Other Party's Telephone Number>>

YOUR TELEPHONE: (        )___________

______________________________  DATE:_____________________

Your signature