Insurance companies can utilize this letter template to seek reimbursement from the person or entity legally responsible for a loss. A liability insurance policy that covers claims arising out of occurrences that take place during the policy period, regardless of when the claim is filed.Plaintiff is an insurance company doing business in the State and County aforesaid. 2. The City of Oakland has a standard claim form that can be used for your convenience. Civil Case Cover Sheet, Judicial Council form CM-010. 4. An "assumption of liability" form letter is available. TPL then determines if the Medicaid program has paid any injury-related medical claims and will pursue repayment from the responsible party. Notification. This Addendum No. 3 forms a part of the Contract Documents and modifies the original. Request for Proposal Documents. 2. Contractor or the County may also be referred to individually as a "Party" or jointly as the "Parties".