Activity
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Name_____________________________


 

Power Problem

At Your Side Insurance
Big Business Way
The City, Any State 00000

Dear Mr. Plugd,

We're sorry to learn of your recent power outage and the damage that it caused. At Your Side Insurance is here to help. Please fill out the form below and return it as soon as possible so that we may process your claim. Thanks for your prompt attention to this matter, and remember At Your Side is "at your side” during times of crisis! We handle many other kinds of insurance and would be happy to discuss them with you at any time. I look forward to hearing from you.

Sincerely,
Ed Juster
Account Representative

Instructions: Fill in the items that were damaged or lost due to weather conditions, the number of each, the cost of the items, and the total for each. Then add the amounts for the items to find the total of your loss. After you have completed the chart, please answer the questions below and include your signature.

Item Quantity Cost Total
Oranges 2 1/2 lbs.
Milk 1 gallon
Hamburger 3 lbs.
Butter 2 lbs.
Eggs 18
whole chicken 2 lbs.
  Total:

Today's date: ___________________
Your location: ___________________
Resource used to gather prices for lost items: _______________________________________
How were the items damaged? __________________________________________________
Your Signature (indicates that you certify the above information to be truthful and correct):
Eun Plugd


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