[your  info including address]

[date]

[insurance co. info including name of adjuster handling claim and address]

Claim number: _________________

Loss date: ________________

Dear Adjuster,

With regards to the insurance claim referenced above, please accept this letter and the documentation attached as my total loss payout request.

In accordance with my rights to be brought back whole and as proof of my loss I submit the enclosed appraisal report completed by Tony Rached an independent, licensed and professional appraiser. His report indicates my vehicle’s market value to be $—–.

I hereby demand to be fully indemnified for this loss, and as such, please remit payment for $—- within 7 days of receipt of this notice as well as an additional $150 as reimbursement for my appraisal cost.

Respectfully,
<sign/print>