AUTOMOBILE CLAIM
REPORT

We at Hudson & Muma 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!

Remember, without complete information, we may be delayed in producing your quote, so please complete ALL applicable fields.

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


    Date of Loss(when claim happened):*

     

     

    Insured Information


    Type of Customer*:Personal CustomerCommercial Customer





    [text Policy-Number(if available) placeholder "Policy Number"]

     

     

    ACCIDENT/LOSS INFORMATION:

    Location of Accident/Loss (include City)*:

    Authoity Contacted (enter NONE indicate so)*:

    Report/Incident Number:

    Insured Vehicle Involved (Yr/Make/Model)*:

    Other Vehicle Involved (Yr/Make/Model):

    Please describe what happened*:

    Who was at fault:InsuredOther Driver

    Describe any Violations or citations Issued to Insured (enter NONE indicate so)*:

    Describe any Violations or citations Issued to Other Driver (enter NONE indicate so)*:

     

     

    DRIVER INFORMATION:

    Driver Name:*

    Relation to Named Insured:SelfOther

    If Other, describe:

    Vehicle Used with Permission?:YesNo

     

     

    Other Driver Name:

    Other Driver Phone:

    Other Driver Address:

    Other Driver Insurance Poloicy Number and Company:

     

     

    DAMAGE INFORMATION:

    Is Your Car Driveable?:

    Have You Received an Estimate to Repair Your Vehicle?:YesNo

    Estimated Damage and Description of Damage to Your Vehicle:

    Estimated Damage and Description of Damage to Other Vehicle:

    Describe Any Other Property Damaged:

     

     

    Where and When Can Your Vehicle Be Seen:

     

     

    Was Anyone Injured (your vehicle occupants, pedestrians or other vehicle occupants)?:
    YesNo

    Describe Injuries:

    Name and Address of Witness1:

    Name and Address of Witness2:

    Note On Physical Damage Coverage:

    Physical Damage Coverage for Vehicles:

    Check your policy or check with Hudson & Muma to determine the type of deductible which 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

     

     

    SPECIAL INSTRUCTIONS:

     

     

    NOTES:

     

     

    Attachments:

    If you have any applicable documents, please attach here.


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    Name of person completing form:*

    Confirmation Email Address:*

    (We need this to send you a confirmation receipt for this form.)