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I have been requested to submit a claim-free letter. What form do I need to complete?

Policies canceled either by the insured's request or for non-payment are routinely reviewed for reinstatement by a customer care specialist, over the phone in our customer service department. If the policy is considered for reinstatement, a Claims Free Letter must be submitted within 24 hours before we can reinstate the policy and process the agreed payment amount. A Claims Free Letter can be sent either by mail, fax or overnight mail. If you have already spoken with a representative and you have been requested to complete a Claims Free Letter please follow the instructions below:

By Email

To send your Claims Free Letter via email, please highlight and copy the information listed below using your mouse then click on the following link: Send us an Email. Please fill in your email address in the required field, then place the information below in the Question Data box of the email form and fill in the blanks. At the bottom of the screen click continue. You will be asked to verify your contact information, choose Submit Question then click Finish Submitting Question. After you submit your question you will be given a reference number, please retain this number for your records. You will be contacted by a customer care specialist within 24 hours to process your payment.

Automobile Policy Number:______________

Today's Date:___________________

This letter is to confirm there have been no losses or potential losses that may result in any claim being filed against policy number ____________________ from 12:01am on (the date your policy canceled)________________________ to the date and time this letter is emailed and receipt is confirmed by a 21st Century Insurance representative.

______________________________ (Named Insured Signature)

______________________________ (Second Named Insured Signature, if applicable)

______________________________ (Print Named Insured)

______________________________ (Print Second Named Insured, if applicable)

By Fax

Please print and complete the bottom portion of the form below located under the heading File Attachments. You may fax this form to,

  • California Residents 888-842-3057(FAX)
  • Non-California Residents 866-447-2611(FAX)

we must receive this information within 24 hours. Once received a representative will contact you to process your payment.

By Mail

You may also mail the completed form and payment within 24 hours by OVERNIGHT MAIL to the following address:

21st Century Insurance Billing Specialist Unit
3 Beaver Valley Rd
Wilmington, DE 19803

****Note: If you do not hear from our office within 48 hours please contact our office toll-free at 1-800-241-1188. We are available 7:00 AM until midnight in your respective time zone. Our Interactive Voice Response system (IVR) and website are available 24-hours a day, 7-days a week****

File Attachments

Claims Free Letter.pdf
 

Topics

General Information
State Forms
Claims
 

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