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Claims Form
Please utilize this website form to report a new auto claim.
CLAIMANT INFORMATION
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.
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In order to continue, please provide the following:
Your Name
*
Your Telephone#
*
Your Email Address
*
GENERAL INFORMATION
SELECT THE APPLICABLE DESCRIPTION :
*
I am an attorney or legal representative of the claimant
I am the claimant
I am the insured
I am the Driver
Other
SELECT THE APPLICABLE DESCRIPTION :
*
I am the driver or owner of a vehicle that was in an accident with a vehicle insured by Hereford
I was a passenger in a vehicle that was in an accident with a vehicle insured by Hereford
I was a pedestrian or bicyclist in an accident with a vehicle insured by Hereford.
I was a passenger in the vehicle insured by Hereford
I am the owner or driver of the vehicle insured by Hereford
Other
I AM MAKING A CLAIM FOR, SELECT ALL THAT APPLY :
*
Damage to my vehicle
Damage to other property
Personal injury to myself, a friend, passenger or a family member
Medical Treatment (No-Fault)
Reporting incident but not making a claim
Other
Please note, at the end of this form you will be given the opportunity to upload photos and other documents
PARTY INFORMATION
INFORMATION ABOUT HEREFORD INSURED
Name of Insured
*
Either Insured Name or Policy No. is Required.
OR
Policy #
*
Owner Street Address
Address Line 2, Apt
City
State/Zip Code
INFORMATION ON THE HEREFORD INSURED VEHICLE (VEHICLE 1)
License Plate #
Driver Name
*
Driver Street Address
Address Line 2, Apt
City
State / Zip Code
INFORMATION ON THE CLAIMANT’S VEHICLE (VEHICLE 2)
Owner’s Name
*
Street Address
Street Address Line2
City
State/Zip Code
Primary Telephone
*
Secondary Telephone
Email Address
*
Vehicle Make/Model
License Plate #/State
*
Year/Mileage
*
VIN #
*
Name of Claimant’s Insurance Company
*
Policy #
Where is vehicle now?
*
Contact Telephone #
Is damage to property other than a vehicle?
Yes
No
Description of damage
*
INFORMATION ABOUT THE DRIVER OF THE CLAIMANT’S VEHICLE
SAME AS ABOVE?
Driver’s Name
*
Street Address
*
Street Address Line2
City
*
State/Zip Code
*
Primary Contact Telephone
*
Secondary Contact Telephone
Email Address
Driver’s License#/State
ACCIDENT INFORMATION
Date
*
Time
*
City
*
Description of Accident, Include Address or Intersection
*
Point of impact to Hereford Insured Vehicle
Select Point of Impact
Driver’s Side Front Door
Driver’s Side Front Quarter Panel
Driver’s Side Rear Door
Driver’s Side Rear Quarter Panel
Front Left
Front Middle
Front Right
Rear Left
Rear Middle
Rear Right
Right Side Front Door
Right Side Front Quarter Panel
Right Side Quarter
Right Side Rear Door
WindScreen
Point of impact to Other/Claimant Vehicle
Select Point of Impact
Driver’s Side Front Door
Driver’s Side Front Quarter Panel
Driver’s Side Rear Door
Driver’s Side Rear Quarter Panel
Front Left
Front Middle
Front Right
Rear Left
Rear Middle
Rear Right
Right Side Front Door
Right Side Front Quarter Panel
Right Side Quarter
Right Side Rear Door
WindScreen
Description of Damage to Claimant’s Vehicle
*
Was the vehicle towed?
*
Yes
No
Unknown
Was the vehicle drivable?
*
Yes
No
Unknown
Did the police come to the scene?
*
Yes
No
Unknown
Did an ambulance come to the scene?
*
Yes
No
Unknown
Did Anyone Leave In Ambulance?
*
Yes
No
Unknown
Were There Any Witnesses?
*
Yes
No
Unknown
Do You Have Any Pictures?
*
Yes
No
Unknown
OCCUPANTS OF VEHICLE
Was the person injured?
Yes
No
Injured Person’s Name
*
Street Address
*
Street Address Line2
City
*
State/Zip Code
*
Primary Telephone
*
Age/Relationship
Email Address
Is she/he represented by an attorney
Yes
No
Attorney name
*
Street Address
Street Address Line2
City
State/Zip Code
Primary Telephone
Which Vehicle was this person in
Hereford
Pedestrian/Bicyclist
Other
Description of Injuries
*
Treatment dates and by whom:
WITNESS INFORMATION
ARE YOU AWARE OF ANY WITNESSES TO THE ACCIDENT?
Witness Name
Street Address
Street Address Line2
City
State/Zip Code
Primary Telephone
Was the Person in the Vehicle Insured by Hereford?
Yes
No
Was the Person in one of The Other Vehicles?
Yes
No
If the person was not in any of the vehicles, provide a brief description as to their location
Do you know this witness?
*
Yes
No
If yes, what is the relationship?
UPLOAD YOUR DOCUMENTS
Upload Your Documents
IF YOU PREFER TO EMAIL YOUR DOCUMENTATION, UPON COMPLETION OF THIS SUBMISSION YOU WILL RECEIVE A CONFIRMING EMAIL, WHICH WILL INCLUDE INSTRUCTIONS ON HOW TO EMAIL THE DOCUMENTS TO HEREFORD INSURANCE COMPANY.
Upload Document
SUBMIT YOUR INFORMATION
THANK YOU FOR PROVIDING THE INFOMATION. AS PREVIOUSLY EXPLAINED, SUBMISSION OF THIS INFORMATION ALLOWS HEREFORD TO REVIEW THE MATTER AND DETERMINE IF A CLAIM SHOULD BE OPENED, IT DOES NOT MEAN THAT THIS IS A VALID CLAIM.
HEREFORD INSURANCE COMPANY WILL CONTACT YOU. THERE IS NO REASON TO SUBMIT THIS INFORMATION AGAIN.
I UNDERSTAND THAT SUBMISSION OF THIS INFORMATION DOES NOT ESTABLISH A VALID CLAIM.
×
SUBMISSION INFORMATION
×
CONFIRMATION
Are You Sure, You Want To Add Additional Information ?
