Personal Auto Claim Form

"Guiding Your Claims Process"

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At the Oberman Companies, we know that filing a claim is an unexpected event that can be stressful. Our role is to help guide you through the claims process. To get started, we need some details to expedite the service.

NOTE: Report claims or notice of potential claims as soon as possible. Please DO NOT wait to report a claim because you do not have ALL the loss details. Additional information can be provided to us at a later date.

Contact Info

Your Name(Required)

First Last

How Can We Reach You?

Please Provide Your Contact Information

Your Email Address(Required)

Preferred Contact Method(Required)

Your Phone(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Secondary Contact Name

Secondary Phone

Incident Report

Please Fill Out All Requested Details

For Record Purposes Only At This Time?(Required)

Yes

Unsure At The Moment

Date of Loss(Required)

MM slash DD slash YYYY

Time of Loss (if known)

Hours

Minutes

AM/PM

Type of Loss(Required)

Collision

Comprehensive

Did The Collision Involve Another Vehicle?(Required)

Yes

Location of Accident(Required)

Description of Damage(Required)

Were the Authorities Called (e.g. Fire, Police, etc.)(Required)

Yes

Name of Precinct, Town/City/State That Responded + Case #(Required)

Insured Vehicle Information (I.V.)

Year, Make, Model, Color(Required)

License Plate # + State(Required)

Last Six Digits of the VIN(Required)

Name of Insured Driver(Required)

First Last

Driver Contact Info(Required)

Where Can the Vehicle Be Seen?(Required)

Is The Vehicle Drivable(Required)

Yes

Describe Damage(Required)

Other Vehicle Information (O.V.)

Was The Accident A Hit And Run?(Required)

Yes

Year, Make, Model, Color(Required)

License Plate # + State(Required)

Name of Owner(Required)

First Last

Owner's Contact Info(Required)

Owner's Insurance Carrier(Required)

Owner's Policy Number, If Known

Driver's Name(Required)

First Last

Driver's Contact Info(Required)

Describe Damage To Other Vehicle

Legal

Bodily Injuries?(Required)

Yes

Possible

Briefly Describe Any Possible Bodily Injury Claims(Required)

Names of Injured Drivers/Passengers(Required)

Injury Information(Required)

Did The Claimant Indicate That They Would Seek Medical Attention?(Required)

Yes

Did The Claimant Go to a Hospital or Urgent Care Facility?(Required)

Yes

Name of Medical Facility, If Known

Was An Ambulance Called?(Required)

Yes

Claimant's Attorney

First Last

Attach Representation Letter, Summons or Email From Attorney

Max. file size: 98 MB.

Documentation

Were Photos or Video Taken of the Accident/Damage?(Required)

Yes

Upload Photos and Videos, If Possible

Drop files here or

Max. file size: 98 MB.

(Note: You must have one or both before making both temporary emergency repairs and/or permanent repairs.) *If you are transmitting photos/video in a file sharing software, please make sure Oberman and/or the carrier can open the software and meets size requirements. If you are saving video, please make a backup copy.

Additional Details

Every insurance policy has a "Duties in the Event of Loss or Damage" section. For simplicity's sake, we have included a generic one from Insurance Services Office (I.S.O.):

2. Duties In The Event Of Accident, Claim, Suit Or Loss

We have no duty to provide coverage under this policy unless there has been full compliance with the following duties:

a. In the event of "accident", claim, "suit" or "loss", you must give us or our authorized representative prompt notice of the "accident" or "loss". Include:

(1) How, when and where the "accident"

or "loss" occurred;

(2) The "insured's" name and address;

and

(3) To the extent possible, the names and addresses of any injured persons and witnesses.

b. Additionally, you and any other involved "insured" must:

(1) Assume no obligation, make no payment or incur no expense without our consent, except at the "insured's" own cost.

(2) Immediately send us copies of any request, demand, order, notice, summons or legal paper received concerning the claim or "suit".

(3) Cooperate with us in the investigation or settlement of the claim or defense against the "suit".

(4) Authorize us to obtain medical records or other pertinent information.

(5) Submit to examination, at our expense, by physicians of our choice, as often as we reasonably require.

c. If there is "loss" to a covered "auto" or its equipment, you must also do the following:

(1) Promptly notify the police if the covered "auto" or any of its equipment is stolen.

(2) Take all reasonable steps to protect the covered "auto" from further damage. Also keep a record of your expenses for consideration in the settlement of the claim.

(3) Permit us to inspect the covered "auto" and records proving the "loss" before its repair or disposition.

(4) Agree to examinations under oath at our request and give us a signed statement of your answers.