Type of Claim: Automobile

Please fill in applicable fields (* denotes required field). Once completed, please click Submit Claim at the bottom of this form. A claims adjuster will contact you shortly.

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals, for the purpose of misleading, information concerning any fact material thereto, is subject to criminal and/or
civil penalties.

For emergency claims requiring immediate attention occurring after hours (evenings, weekends or holidays) please contact a Cumberland Representative by telephone at 1-800-232-6992.

Policy Symbol (ex. HON):*
Policy Number (ex. 1234567):*
Policyholder Name:*
Name of Person Reporting Claim:*
Mailing Address:*
Street:
City:
State:
Zip:
Loss Location:*
Street:
City:
State:
Zip:
Vehicle/Driver Information:
Vehicle Year:
Vehicle Make:
Vehicle Model:
VIN (optional):
Driver's Name:
Driver's Address:
Date of Occurrence:*
/
/
Primary Contact Name:*
Secondary Contact Name:
Primary Contact Telephone:*
Secondary Contact Telephone:
1.
2.
Description of Damages (What Happened?):*
Email Address:
Agent:
Name of Lender:
Did a Police or Fire Department respond?
If so, name of responding department:
Claimant:
Name:
Address:
City:
State:
Zip:
Telephone Number:
Do you have a repair estimate:*
If yes, approximate $ amount of damages:
If available, please attach photographs depicting the loss:
Enter the text you see in the security image:


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