Hannum Insurance Agency, Inc.
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Auto Claim
Name of Person Reporting Claim
*
First
Last
Your Phone Number
*
Policy Number (if known)
*
Relationship to Insured
*
Self
Spouse
Claimant
Claimant's Agent/Company
Parent
Child
Other
If claimant or claimant's agent, what is the name of the insurance company?
*
If other, please specify relationship to insured.
*
Accident Information
If more than two vehicles were involved and/or if passengers were injured, please write an additional vehicle and injured party descriptions in the remarks.
Location of Accident
*
Authority Contacted
*
Description of Claim
*
Injuries
*
Yes
No
Insured Vehicle Information
Year
*
Make
*
Model
*
Last 6 digits of VIN
*
Describe Damage
*
Insured Driver Information
If passengers were injured, please write an additional injured party description in the remarks.
Name
*
First
Last
Date of Birth
*
Driver License Number
*
Was it being used with permission?
*
Yes
No
If injured, please describe injury.
*
Other Vehicle Information
If more than two vehicles were involved, please write an additional vehicle description in the remarks.
Year
*
Make
*
Model
*
Name of Insurance Company
*
Owner of Car's Name
*
First
Last
Descirbe Damage
*
Other Driver Information
If passengers were injured, please write an additional injured party description in the remarks.
Name
*
First
Last
If Injured, please describe injury.
*
Submission
An agent will contact you within one business day unless you request otherwise.
Additional Remarks
*
Submit
Back to Home
Home
Quotes
Homeowners Quote
Automobile Quote
Watercraft Quote
Health Quote
Motorcycle Quote
Renters Quote
Endorsements
Property Endorsement
>
Address Change
Mortgagee Change
Scheduled Items Change
All Other Property Changes
Auto Endorsement
>
Address Change
Vehicle Change
Driver Change
Lienholder Change
>
Add Lienholder
Change Lienholder
Delete Lienholder
Coverage Change
>
Add Coverage
Delete Coverage
All Other Auto Changes
Report A Claim
Auto Glass Claim
Auto Claim
Property Claim
Request Documents
Request New ID Cards
Request A Certificate
Request A Policy Declaration
Contact Us
About Us
Our History
Our Staff
Our Companies
Other Services
Social Media
Feedback
UA-99323310-1