Claim

YOU HAVE SELECTED TO PROVIDE HEREFORD INSURANCE COMPANY WITH NOTICE OF AN ACCIDENT OR POTENTIAL CLAIM. ONCE SUBMITTED, HEREFORD WILL VERIFY THE DETAILS OF THE MATTER, AND IF APPROPRIATE, A CLAIM WILL BE OPENED.

IT IS IMPORTANT TO NOTE THAT WHETHER A VALID CLAIM EXISTS AND/OR IF ANY PAYMENT WILL RESULT DEPENDS ON MANY FACTORS, INCLUDING BUT NOT LIMITED TO, IF COVERAGE EXISTS, THE TYPE OF COVERAGE, THE LIABILITY OR FACTS REGARDING THE CLAIM, THE DAMAGES, TIMELINESS OF THE NOTICE OF CLAIM, AS WELL AS OTHER FACTORS.

PLEASE NOTE THAT ADDITIONAL INFORMATION MAY BE NEEDED. REGARDLESS OF WHETHER ADDITIONAL INFORMATION IS NEEDED, OR WHETHER A CLAIM IS OPENED OR NOT, SOMEONE WILL CONTACT YOU FOLLOWING REVIEW OF THIS SUBMISSION.

RESUBMITTING THIS FORM OR FILING THE CLAIM THROUGH OTHER MEANS WILL ONLY DELAY THE PROCESS.
BY CONTINUING WITH THIS SUBMISSION, YOU ARE ACKNOWLEDGING THAT YOU HAVE READ, UNDERSTOOD AND AGREE WITH THE ABOVE NOTICE.

refno

In order to continue, please provide the following:

Your Name *

Your Telephone#*

Your Email Address*

Claims Form

CLAIMANT INFORMATION

INFORMATION ABOUT HEREFORD INSURED

INFORMATION ON THE HEREFORD INSURED VEHICLE (VEHICLE 1)

INFORMATION ON THE CLAIMANT’S VEHICLE (VEHICLE 2)

INFORMATION ABOUT THE DRIVER OF THE CLAIMANT’S VEHICLE

ARE YOU AWARE OF ANY WITNESSES TO THE ACCIDENT?

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