[Insured legal name]
[Street address]
[City, State ZIP]
October 4, 2026
To
Old Republic Insurance Company - Loss Runs Department
Contact not verified - check the insurer's official site (https://www.oldrepublic.com) or ask your agent
Re: Loss run request - [Insured legal name] - USDOT [USDOT #]
To whom it may concern,
- Named insured
- [Insured legal name]
- USDOT number
- [USDOT #]
- MC/MX docket
- N/A
- Policy number(s)
- All policies issued to the named insured
- Period requested
- Last 5 years (or full history with your company, if shorter)
Please provide currently valued loss runs for the named insured below, covering the last 5 years of coverage with your company, for auto liability, motor truck cargo, physical damage and general liability (all that apply).
Please include all open and closed claims with dates of loss, paid, reserved and total incurred amounts, along with the policy periods. If there were no claims, please confirm "no losses" in writing.
Please send the loss runs to: [Your name], Owner - [Email].
I am an authorized representative of the named insured and authorize Old Republic Insurance Company to release these loss runs to the contact above.
Sincerely,
Print name: [Your name]
Title: Owner
Date: October 4, 2026