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ClaimsF

Online Auto Claim Form




REPORT AN AUTO CLAIM
UMIALIK INSURANCE COMPANY
a member of the
WESTERN NATIONAL INSURANCE GROUP
*   Denotes required fields.
Umialik Policyholder Information
Type of Policy  
Policy Number  
Umialik Policyholder's Name  
Address  
City  
State  
Zip  
Contact Name  
Contact Phone  
Driver's Name  
Vehicle Description (Year, Make, Model)  
Person Submitting Claim is:
E-mail of Person Submitting Claim:   
Other Party Information
Name of Other Party  
Address  
City   
State  
Zip  
Contact  
Contact Phone  
Driver's Name  
Vehicle Description (Year, Make, Model)  
Additional Other Parties and/or Witnesses
If additional other party information, please enter in the text box below.  
Loss Information
Date of Loss  
Loss Location  
Location of Damaged Property  
Description of Accident or Loss  
Other Vehicles & Property Damage Information
Were there any other vehicles damaged?  
No Yes
If yes, how many?  
If yes, please provide details.  
Was there damage to property other than vehicles?  
No Yes
If yes, please provide details.  
Injury Information
Was anyone injured?  
No Yes
If yes, how many?  




Name of
Injured Party(s)
Description of
Injury
Telephone
Number
 
 
 
 
 
 
 
 
If more than 4 injuries, please list below  
Please enter the words you see in the box, in order and separated by a space. If you are unsure what the words are, click the reload button next to the distorted words.