Report Claim | Hummel Group

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Name
First Name
Last Name
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Address* This field is required.
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Phone Number* This field is required.
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Email* This field is required.
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Are you reporting a home or auto claim?
Home
Auto
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Date of Loss
Date
Month
Day
Year
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Time of Loss
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Hour
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Minutes
PM
AM
PM
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Where did the Incident Occur?
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What Happened?
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Who was Driving?* This field is required.
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Year, Make & Model of Your Vehicle* This field is required.
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Is the vehicle drivable?
Yes
No
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Describe damage to vehicle:
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Describe injuries
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How many other vehicles were involved?
Please Select
Please Select
None
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2
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5
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Additional Vehicle 1
Year, Make, and Model of vehicle
Who was driving?
Phone number
Address
Description of damage to vehicle
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Additional Vehicle 2
Year, Make, and Model of vehicle
Who was driving?
Phone number
Address
Description of damage to vehicle
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Additional Vehicle 3
Year, Make, and Model of vehicle
Who was driving?
Phone number
Address
Description of damage to vehicle
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Additional Vehicle 4
Year, Make, and Model of vehicle
Who was driving?
Phone number
Address
Description of damage to vehicle
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Additional Vehicle 5
Year, Make, and Model of vehicle
Who was driving?
Phone number
Address
Description of damage to vehicle
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Was there a police report?
YESNO
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Police Report Information
Police report number
Investigator's name
Were any citations given? Provide details.
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Add all passengers and their phone numbers.
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Add all witnesses and their phone numbers.
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Is a rental car needed?
YESNO
Should be Empty: