Your Préname/Name
Address
Postal Code/City
[Name of your insurer]
Address
Postal Code/City
Done so; [your city], on [précate the date].
Object : Report of loss covered by liability policy n° [indicate your policy number]
Madam, Sir,
As of [state date of loss], I [décried loss occurred].
In fact, it turns out that [describe the facts and the origin of the loss and the way in which you caused it].
&As I am fully responsible, I wish to invoke my civil liability in order to avoid my fault. I remain at your disposal for any additional information.
I would like to thank you, Madam, Sir, for your kind attention.
[Your signature]