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.

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): * This field is required

Policy Number (ex. 1234567): * This field is required

Policyholder Name: * This field is required

Name of Person Reporting Claim: * This field is required

Mailing Address: *

Street:
City:
State:
Zip:

This field is required

Loss Location: *

Street:
City:
State:
Zip:

This field is required

Vehicle/Driver Information:

Vehicle Year:
Vehicle Make:
Vehicle Model:
VIN (optional):
Driver's Name:
Driver's Address:

Date of Occurrence: *

This field is required

Primary Contact Name: * This field is required

Secondary Contact Name:

Primary Contact Telephone: * This field is required

Secondary Contact Telephone:

1.
2.

Description of Accident (What happened?): *This field is required

Description of Damages: *This field is required

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: * This field is required

If yes, approximate $ amount of damages:

If available, please attach photographs depicting the loss:

Delaware Fraud Statement: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, files a statement of claim containing any false, incomplete or misleading information is guilty of a felony.

Maryland Fraud Statement: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

New Jersey Fraud Statement: Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties.

Pennsylvania Fraud Statement: Any person who knowingly and with intent to injure or defraud any insurer files an application or claim containing any false, incomplete or misleading information shall, upon conviction, be subject to imprisonment for up to seven years and the payment of a fine of up to $15,000.

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