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Uninsured Motorist Claim Form

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UNINSURED MOTORIST CLAIM FORM

Claimant / Insured Information

Date of Birth:    Phone:    Email:

Policy Information

Policy Period From:    To:

Coverage Selected:

Incident Details

Date of Loss:    Time:

Uninsured / Underinsured Motorist Information

Other Vehicle Make/Model:    Color:    License Plate (if known):

Was another driver identified?

Injuries and Property Damage

Estimated Property Damage Amount: $    Total Medical Expenses to Date: $

Medical Treatment & Wage Loss

Are you missing work due to injury?

Witnesses & Police

   If yes, Agency:    Report/Incident No:

Evidence & Documentation Checklist

Please indicate documents attached:






Coverage, Assignment & Authorization

Claimant certifies that the information provided in this form is true, complete, and correct to the best of claimant's knowledge. Claimant authorizes the insurer and its representatives to obtain and review medical records, employment and wage records, billing and payment information, and other relevant documentation reasonably necessary to evaluate this claim. Claimant further agrees to cooperate with any reasonable investigation, to execute necessary releases and assignments related to recovery or subrogation, and to promptly notify the insurer of any change in condition or additional treatment.

Subrogation / Recovery: If the insurer pays benefits under uninsured or underinsured motorist coverage, claimant acknowledges the insurer's right to pursue recovery from negligent third parties and assigns to the insurer any rights of recovery to the extent of benefits paid. Claimant agrees not to prejudice the insurer's subrogation or recovery rights.

Fraud Warning: Any person who knowingly submits a false or fraudulent claim for payment of a loss is subject to civil and criminal penalties under applicable law, including denial of benefits and potential fines or imprisonment.

Claim Amount and Relief Requested

Certification and Applicant Acknowledgment

I certify under penalty of perjury that the foregoing statements are true and correct. I understand that this form is a formal claim notification and does not, by itself, constitute acceptance of coverage or guarantee of payment. I agree to furnish additional supporting evidence and to execute any releases necessary for the insurer to evaluate and process this claim.

Claimant Name:

Signature:

Date:

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What an Uninsured Motorist Claim Form Is

An Uninsured Motorist Claim Form is the document a policyholder files with their own insurer to request coverage when the at-fault driver lacks liability insurance or is unidentified. It documents the accident, lists medical and repair expenses, and asks the insurer to evaluate benefits under uninsured or underinsured motorist coverage. The form becomes part of the insurer’s claim file and usually includes claimant details, accident narrative, witness names, police report references, and supporting invoices or medical records required to establish loss and damages.

Why this Form Matters to Policyholders and Insurers

Filing the Uninsured Motorist Claim Form opens a formal claim process, creates an insurer record, and preserves rights under the policy. Electronic execution is generally enforceable under the federal ESIGN Act (15 U.S.C. ch. 96) and state UETA statutes; confirm any consumer disclosure requirements for consumer-facing claims.

Why this Form Matters to Policyholders and Insurers

Who Typically Completes This Form

Policyholders, their legal representatives, and insurance adjusters complete or collect this form when a covered loss involves an uninsured or underinsured driver.

  • Policyholder or insured: Completes details about the accident, injuries, and damages for their own claim submission.
  • Authorized representative: Attorneys or claim representatives may fill forms and submit on behalf of insureds with written authorization.
  • Insurance adjuster intake: Insurer staff may use the form to document initial coverage eligibility and notes for the claim file.

Different parties may prepare versus sign the form; verify authority and required attachments before submission.

Core Sections to Expect on a Professional Form

A well-structured Uninsured Motorist Claim Form organizes claimant identity, accident facts, proof of uninsured status, loss details, authorization to obtain records, and signature fields for consent and verification.

Claimant Info

Full legal name, contact details, policy numbers, and relationship to insured where applicable; used for identification and correspondence.

Accident Details

Date, time, location, weather, vehicle descriptions, and brief narrative that establishes facts and sequence leading to the loss.

Uninsured Evidence

Police report number, at-fault driver info if known, or insurer denial letter when another driver lacked coverage.

Damages and Losses

Itemized medical bills, repair estimates, wage-loss documentation, and dates of treatment or repair with supporting invoices.

Authorizations

Consent to obtain medical records, a release for repair invoices, and permission to contact providers or third parties for verification.

Signature Block

Signed and dated declaration under penalty of perjury that information is true; may include electronic-signature acceptance language.

Step-by-Step: Filling and Submitting the Form

A concise process reduces processing time and avoids return requests for missing information.

  • 01
    Gather Documents: Collect police reports, medical bills, repair estimates, and policy ID information before starting.
  • 02
    Complete Fields: Enter claimant, accident, and loss details carefully using required formats.
  • 03
    Attach Proof: Upload supporting invoices, photos, and police reports to the submission package.
  • 04
    Sign and Submit: Sign in the specified location and submit by the insurer’s accepted method.

Where Your Form Goes After You Submit It

Understanding routing helps set expectations for response and next steps from the insurer or claims administrator.

  • Intake: Carrier intake team logs the form and opens a claim file for review.
  • Assignment: An adjuster or examiner is assigned and reviews the submitted materials.
  • Investigation: Insurer verifies uninsured status and requests additional records if needed.
  • Resolution: Claim is accepted, denied, or negotiated for settlement based on policy terms.

Digital Submission and Format Considerations

Many insurers accept electronic submission; ensure your files meet size, format, and authentication requirements before uploading.

  • File Formats: PDF, DOCX, and JPG commonly accepted.
  • Authentication: Email or SMS code verification may be required.
  • Integrations: APIs connect with common systems like Salesforce or NetSuite.

Configuring an Online Claim Workflow

Key workflow settings reduce manual steps and improve data consistency for high-volume claim intake.

Field | Configuration Purpose | Typical setting
Signature Type Electronic signature | Email + audit trail
Authentication Two-factor | SMS code or email link
Conditional Fields Enable | Show accident details only when needed
Template Save Reusable | Save as insurer intake template

Essential Data Elements to Include

Claimant Name: Full legal name
Policy Number: Insurer ID
Accident Date: MM/DD/YYYY
Police Report: Report number
Injury Summary: Brief description
Supporting Proof: Bills and photos

Documents to Bundle with the Claim Form

Attach clear, itemized records to accelerate review; unlabeled or partial invoices cause frequent processing delays.

Police Report

Provide the official report or accident number to corroborate the event and assist in verifying the other party’s insurance status; include jurisdiction and reporting officer if available.

Medical Bills

Attach itemized statements showing dates of service, provider names, CPT or billing codes, and total billed amounts for each treatment episode related to the collision.

Repair Estimates

Include written estimates or final repair invoices with VIN, labor, parts breakdown, and photos of vehicle damage to substantiate property loss.

Proof of Uninsured Status

If available, include the other insurer’s denial letter, citation evidencing a hit-and-run, or documentation showing the at-fault driver had no coverage.

Timing to Keep in Mind

Timely reporting and submission preserve coverage rights; follow policy notice requirements and state filing windows.

Report to Police:

Report at the scene or as soon as possible; some jurisdictions require prompt notification.

Notify Insurer:

Provide initial notice to your carrier according to your policy—often within days of the collision.

Submit Claim Form:

Send the completed form and attachments promptly; delays may complicate investigation.

File Suit Window:

Statute of limitations for personal injury varies by state, commonly 2–6 years; check state law.

Records Retention:

Keep originals for the claim lifecycle and legal preservation periods.

Key Processing Milestones for a Claim

Typical stages from intake to resolution highlight what to expect and when to follow up with the insurer.

01

Claim Intake

Carrier logs the claim and assigns an ID and adjuster.

02

Document Review

Adjuster reviews police report and supporting bills for completeness.

03

Coverage Determination

Insurer determines applicability of uninsured motorist coverage.

04

Resolution or Next Steps

Claim is paid, denied, or escalated to negotiation or litigation.

Notarization and Witness Steps (If Required)

Some insurers or states may require notarized signatures or witness attestations; follow local rules where applicable.

01

Check Policy Language

Determine whether the insurer or state requires notarization for claimant attestations.

02

Locate Notary

Arrange an in-person notary or use a permitted RON provider if allowed by state law.

03

Provide ID

Bring government-issued photo ID for identity verification during notarization.

04

Witness Requirement

Confirm whether witnesses are required and how many should sign the form.

05

Record Retention

Notary journals or RON audio-visual records may be retained per state rules.

06

RON Considerations

If using remote notarization, ensure the state permits RON and follow identity-proofing steps.

07

Sign in Presence

For in-person notary, sign only in the notary’s presence to validate the acknowledgement.

08

Submit Notarized Copy

Include the notarized signature page when submitting to the insurer if required.

Common Errors That Slow Claims

  • Incomplete documentation: Missing police report numbers, unsigned authorizations, or incomplete medical billing statements force carriers to request additional records and extend resolution time.
  • Incorrect policy identifiers: Typing wrong policy or claim numbers directs records to incorrect files and delays processing while staff reconcile the error with claimant details.
  • Late submission: Waiting weeks to submit the form after treatment or repair often complicates verification and may risk coverage disputes or denial.
  • Insufficient proof of uninsured status: Failing to provide a denial from another insurer, a hit-and-run report, or other confirming evidence can result in claim rejection.

Consequences of Errors or Misstatements

Claim Denial: Incomplete or false information can result in denial.
Policy Cancellation: Material misstatements may trigger insurer cancellation.
Legal Exposure: Fraudulent statements can lead to civil or criminal liability.
Financial Liability: You may be liable for unreimbursed losses and legal costs.
Delayed Payment: Missing proof or signatures extends settlement timelines.
Record Corrections: Correction procedures add administrative burden and delays.

State Variations That Often Affect Claims

Notarization, witness rules, and reporting obligations differ by state and can materially affect submission requirements for claims and sworn statements.

Requirement California Florida Texas
Notarization sometimes required often required varies by carrier
Witness Count none typical two witnesses typical none typical
RON Allowed permitted with conditions permitted permitted with conditions
Statute Window varies varies varies

Typical eSignature Vendor Comparison for Claims Submission

Electronic signature platforms vary in price, trial length, and enterprise features; signNow appears first to reflect available plan-level pricing and usage models.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Free Trial 7-day free trial, no credit card Varies by plan Varies by plan Varies by plan Varies by plan
Bulk Send Yes (premium tiers) Yes Varies by plan Yes Varies by plan
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes (BAA available) Varies by plan Varies by plan Varies by plan Varies by plan

Representative Use Cases

Two brief scenarios show how the form fits common claim workflows.

Adjuster Intake Example

Field adjuster collects details on-site and uploads photos using a mobile form

  • One-line accident summary provided to claims desk
  • The carrier opens a file, requests medical authorizations, and schedules a recorded statement to determine uninsured coverage eligibility.

Attorney-Assisted Claim

An injured claimant engages counsel who completes the form and attaches medicals

  • Lawyer submits signed authorization for records retrieval
  • The attorney coordinates subrogation efforts while negotiating a settlement under the insured’s UM/UIM policy limits.

Who May Sign the Form

Policyholder — Named Insured

The named insured or claimant signs to certify accuracy and to provide authorizations. The policyholder’s signature confirms consent to release medical and billing records and binds the claimant to statements made on the form.

Authorized Representative — Agent/Attorney

A licensed representative or attorney may sign with written authority. Representative signatures should be accompanied by a power of attorney, letter of representation, or insurer-approved authorization to avoid questions about authority.

Frequently Asked Questions

Answers to common procedural and technical questions about completing and submitting the Uninsured Motorist Claim Form.


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