START-32643831 ST-White

Policy underwritten by
Alliance United Insurance Company
Named insured: Alan Jeisuan Herrera Madero
Claim number: D177528CA18
Alliance United Insurance Company
PO Box 2927 Date of loss: December 14, 2018
Clinton, IA 52733-2927
Date of mailing: December 31, 2018

Alan Jeisuan Herrera Madero

7182 Braemar Ave
Highland, CA 92346-3231

Dear Alan Jeisuan Herrera:

We are writing to you regarding the loss referenced above.

We contacted the police department to secure a copy of the police report.

We need to confirm you were not driving under the influence of alcohol or
drugs (including prescription drugs) and confirm the facts of this loss.

We reserve the right to deny coverage for an accident or loss if you or any
insured person has concealed or misrepresented material information or
engaged in any fraudulent conduct in connection with the presentation,
investigation processing or settlement of a claim. If we deny coverage,
you, or the insured, would be required to reimburse Alliance United
Insurance Company for any claim payments, administrative costs or
processing costs we incur. This reimbursement would include any legal or
processing fees incurred during the collection of this reimbursement.

Once we receive the requested information, we will process the claim.

If you have any questions, please contact us and have the claim number
available so we can assist you as quickly as possible.

Sincerely,
Robin Stewart
Claims Team
T 800.508.5833, ext. 1663860
F 800.277.2011
robins@allianceunited.com
Alliance United Insurance Company
For your protection California law requires the following to appear on this form: Any person who
knowingly presents false or fraudulent claim for the payment of a loss is guilty of a crime and may
be subject to fines and confinement in state prison.
 ST-White

Claim Number:D177528CA18
Declaration

I, (printed name)_______________________________,
Alan Jeisuan Herrera Madero being duly sworn
upon my oath, declare that I was not driving under the influence of
alcohol or drugs (including prescription drugs) at the time of the accident,
which occurred on December 14, 2018.
Further affiant sayeth naught.

SIGNATURE:
Alan Jeisuan Herrera Madero
(Printed Name)

(Signature)
12/29/2018
(Date)
For your protection California law requires the following to appear on this
form: Any person who knowingly presents false or fraudulent claim for
the payment of a loss is guilty of a crime and may be subject to fines and
confinement in state prison.
 ST-White

Claim Number:D177528CA18
Declaration

Alan Jeisuan Herrera Madero

I, (printed name)_______________________________, being duly sworn
upon my oath, declare that I was not driving under the influence of
alcohol or drugs (including prescription drugs) at the time of the accident,
which occurred on December 14, 2018.
Further affiant sayeth naught.

SIGNATURE:
Alan Jeisuan Herrera Madero
(Printed Name)

(Signature)
12/29/2018
(Date)
For your protection California law requires the following to appear on this
form: Any person who knowingly presents false or fraudulent claim for
the payment of a loss is guilty of a crime and may be subject to fines and
confinement in state prison.