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Personal Automobile Claim Form
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As you prepare to fill out this form, you will need to have gathered as much information regarding the claim as possible. This might include, but is not limited to, your policy number, the date of the loss, contact information for witnesses or those injured and law enforcement or fire department information. Completing a form takes approximately five to fifteen minutes, and is the exact same process followed when you call in a claim to our offices.

As you complete this claim form, please try to list as many details as possible, because you are the best person to tell us what happened, and because the more information you provide to us, the better we can serve you. All this information could be critical in settling a claim.

Instructions for Submitting this Form to American Modern:

Clicking on the Submit button on the last page of this form will electronically send your information to the American Modern Insurance Group. However, you also have the option of printing the form and faxing or mailing the page(s) to us.

Clicking on the Print button will not submit your information to us. Instead, it will take you to a print friendly page with all your information listed. You can then print that page and fax or mail the form to us. The print friendly page will also include the address or fax number you will need to use to send us claim information.

Note: These instructions will be repeated on the final page before you submit or create the print friendly page.

Fields marked with a * are required for submission.
 
Policy Number:  * Date of Loss:  Year: *
 
Insured Information
Last Name:  *  First:  * MI: 
Street Address:  *
City:  * State:  *
Zip Code:  *  County:  *
Home Telephone:  ( ) *
Work Telephone:  ( ) Ext.
Other Telephone:  ( ) Ext.
Who to Contact: 
Best Time to Contact: 
Email Address: 
Description of Loss: 
 *
Reported By:  *
Full Name:  *
Contact Telephone:  ( ) * Ext. Home Work Other
 
  Would you like to save time with the American Modern Form Assistant? Check the box before you continue if you would like some of your information to be remembered for future use in other forms on our Web site. Only basic policyholder data will be stored, and you are not required to utilize the Form Assistant on this or any other visit to our site. If you are completing this form for someone else or on a computer other than your own, do not select this option.

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Last Updated on April 3, 2003