Your First name/Last name

Address

Postal code/ CITY

[Name of your insurer]

Address

Postal code/ City

Done in [your city], on [specify the date].

Subject: Claim declaration covered by civil liability insurance policy No. [indicate your policy number]

Madam, Sir,

On [indicate the date of the incident], I [describe the incident].

Indeed, it appears that [describe the facts that caused the incident and how you caused it].

Being fully responsible, I wish to activate my civil liability insurance in order to remedy the damage caused. I remain at your disposal for any further information.

Please accept, Madam, Sir, the expression of my best regards.

[Your signature]