Insurance Claim for Uninsured Motorists

INSURANCE CLAIM FOR UNINSURED MOTORISTS

Use this form to report a claim arising from a motor vehicle collision involving an uninsured or underinsured motorist. Complete all applicable sections, attach supporting documentation, and sign the certification below. Failure to provide requested information may delay processing or denial of benefits.

Claimant / Insured Information

Incident Details

Date of loss:    Time of loss:    Location:

Other vehicle registration/state:    Other driver name:

Was the other motorist insured? Uninsured Underinsured Insured (provide insurer below)

Injuries and Medical Treatment

Hospitalized? Yes No

Property Damage

Claimed Damages

Policy Coverage Details

Coverage limit:    Deductible:    Premium:

Policy period from: to:

Uninsured/Underinsured Motorist coverages claimed (select all that apply):

Bodily Injury (BI) Property Damage (PD) Stacking / Multiple vehicle limits Family member coverage

Exclusions, Subrogation, and Authorization

By signing below, the claimant certifies that the information provided in this form and any attachments is true and complete to the best of the claimant's knowledge. The claimant authorizes the insurer and its representatives to obtain and release medical, employment and other records reasonably necessary to investigate, evaluate, and substantiate this claim. The claimant acknowledges that the insurer may seek subrogation or reimbursement from any third party or their insurer for amounts paid under this policy and agrees to cooperate in such recovery, including execution of necessary documents.

Exclusions: Benefits are subject to policy terms, conditions and exclusions, including but not limited to: intentional acts, use of vehicle for unauthorized commercial purposes if excluded by policy, failure to cooperate with investigations, and uninsured motorist coverage limits. Payment under uninsured/underinsured motorist coverage may be reduced by failure to timely notify the insurer, failure to provide requested documentation, or fraudulent statements.

Fraud Warning: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance may be guilty of a criminal act and subject to civil penalties.

Beneficiary / Payee for Payment

Documentation Checklist

Please attach copies of all applicable items; keep originals for your records.

Police report Medical records and bills Repair estimates / photos of damage Witness statements / contact information Proof of lost wages (paystubs, employer verification) Other supporting documentation (specify below)

Additional Statements

I certify under penalty of law that the information contained in this claim form and any attached documents is true, complete and correct to the best of my knowledge. I understand that submission of fraudulent information may result in denial of benefits, termination of coverage, civil or criminal penalties, and restitution. I agree to cooperate with the insurer's investigation, provide requested records, and attend medical examinations if reasonably required.

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