SAMPLE CHANGE OF ADDRESS LETTER

Date:___________________

File #: Claim Number

Employee:____________________

Claimant:_____________________

Name of Claimant

Address (Line 1)

Address (Line 2)

Address (Line 3)

Change of Address

This will notify you of my change of address to the following:

Name

Address

City/State/Zip

Phone Number

Other Information:

_________________________________ _______________

Signature Date