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AUTOMOBILE CLAIM FORM

This form is for the use of customers of Hudson & Muma
and insure-all.com only.

We at Hudson & Muma/Insure-all.Com believe that it is important to
offer our customers the most up-to-date technology available which
will enhance the service they receive. It is because of this
commitment that we are offering this form to aid in generating
accurate applications and forms quickly and efficiently!  

 

 

SUBMITTING THIS FORM YOU ARE AGREEING TO THE CONDITION THAT NO MATERIAL CHANGE WILL BE MADE TO YOUR POLICY UNLESS AND UNTIL YOU RECEIVE CONFIRMATION OF THAT CHANGE FROM A HUDSON & MUMA ASSOCIATE OR AN ASSOCIATE THAT THE INSURANCE COMPANY WRITING THE COVERAGE. 
* Indicates required fields

 



Automobile Claim Report    
 
...

Insured Personal Information

Today's Date:
Insured's Full Name:
Home Phone: xxx-xxx-xxxx
Work Phone: xxx-xxx-xxxx
Policy Number:

Accident/Loss Information

Date of Accident/Claim:  
Location of Accident (incl.
City):		  
Authority Contacted:
Report Number:
Insured Vehicle Description
(Year/Make/Model):
Other Vehicle Description
(Year/Make/Model):
Describe What Happened?
Who Was At Fault? Insured Other Driver
Describe any Violations or
Citations Issued to you or
other driver?		 Yourself:

Other Driver:
Driver Information
Driver Name:
Relationship to Named Insured: Self, or
Vehicle Used With Permission? Yes No
Other Driver Name:
Other Driver Phone:
Other Driver Address:
Other Driver Insurance
Policy Number and
Company:
Damage Information
Estimated Damage to your
vehicle:
Describe Damage to other
vehicle:
Where and when can your
vehicle be seen?
Have you received an estimate
for repairs?

Yes No
If yes, how much was the
estimate?
Describe Any Injuries (your
vehicle's occupants,
pedestrians or other
vehicle's occupants):
Witness 1 - Name and
Address:
Witness 2 - Name and
Address:

Physical Damage Coverage for Vehicles:

Check your policy or check with Hudson & Muma to determine the type of
deductible applies to your vehicle.

Collision =  Damage to YOUR vehicle while it is being driven.

Comprehensive = Damage to YOUR vehicle OTHER THAN COLLISION

Type of Collision Coverage: 
  • 1. Broadened Collision - you will not have to pay the deductible if you
    are PROVEN not at fault.
  • 2. Standard Collision - regardless of fault you will pay your deductible.
  • 3. Limited Collision - you must be LESS THAN 50% at fault or there is
    NO coverage for your physical damage loss
Form Submitted by:
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