Auto Insurance Claim Form

AUTO INSURANCE CLAIM FORM

Claim Information

Claim Number:

Date of Loss:   Time of Loss:

Location of Loss:

Police Report Filed: Yes   Agency / Report No.:

Insured / Applicant Information

Policy Details & Coverage

Policy Type:   Coverage Limits:

Deductible:   Annual Premium:

Policy Period From:   To:

Collision    Comprehensive    Liability    Medical Payments    Uninsured Motorist    Underinsured Motorist    Rental Reimbursement

Vehicle(s) Involved

Injuries & Passengers

Yes    No

Property Damage & Loss Description

Yes    No

Witnesses & Statements

Documentation Checklist

Indicate documents attached (check all that apply)

Photos of damage    Police report    Repair estimate    Medical bills    Tow receipt    Witness statements

Beneficiary / Payment Instructions (if applicable)

If claim proceeds are to be paid to a party other than the insured, provide beneficiary information.

Exclusions & Important Notices

Important: Submission of this claim does not constitute acceptance of coverage or liability. Coverage determinations will be made in accordance with the policy contract. The insurer reserves all rights under the policy, including defenses and exclusions. Known exclusions include, without limitation, loss arising from willful or intentional acts, use of the vehicle for commercial livery without endorsement, racing, or use by an excluded driver.

Fraud Warning: Any person who knowingly and with intent to defraud submits an application or files a claim containing materially false information may be guilty of insurance fraud and subject to criminal and civil penalties.

Declaration, Authorization & Certification

I declare that the information provided in this claim form is true and complete to the best of my knowledge. I understand that the insurer may investigate the circumstances of this claim and may require supporting documentation. I authorize the release of medical, employment, repair, towing, and police records relevant to this claim to the insurer or its representatives. I agree to cooperate with the insurer in any investigation and to execute any documents reasonably necessary to pursue subrogation or recovery rights.

I acknowledge that any payment of loss is subject to policy terms, conditions and applicable deductible, and I will notify the insurer promptly of any changes in my claim circumstances. I further acknowledge that the insurer may offset amounts paid under this claim against other recoveries and that salvage and recovery rights may apply as provided by the policy.

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