Report a Claim (Non-Policyholders)

This form is for use by non-policyholders to file a claim against a driver insured through USA Underwriters. If you are a USA Underwriters policyholder attempting to report a claim on your vehicle, please click on the appropriate button below to be taken to the Policyholder Claim Report form.

I am not a USA Underwriters Policyholder I am a USA Underwriters Policyholder

Are you someone who is filing a claim against a policyholder?(Required)

Yes

Please Select Yes or No.

Your Auto Insurance Carrier(Required)

Please select your auto insurance carrier. If you don't see your carrier listed, select 'Other' and you will be prompted to enter the name of your auto insurance carrier.

Other Carrier(Required)

Please enter the name of your Auto Insurance Carrier. If you don't know who your auto insurance carrier is, contact your agent.

Auto Insurance Policy Number(Required)

Please enter your auto insurance policy number here.

How are you related to this loss?

Policyholder's Policy Number(Required)

Please enter the USA Underwriter's policyholder policy number here.

Policyholder's Driver's License Number(Required)

Please enter your driver's license number.

Claimant Information

Your Full Name(Required)

First Middle Last

Please enter the your legal full name.

Date of Birth(Required)

Please provide the policy holder's date of birth.

Your Mailing Address(Required)

Street Address Address Line 2 City State ZIP Code

Please provide your full mailing address.

Email Address(Required)

Please provide your email address.

Primary Phone Number(Required)

Please provide the best contact number where we can reach you at.

Alternate Phone Number

If you have a secondary or alternate phone number (such as a land line or work/office desk phone), please provide it here. If we can't reach you at the number you provided as your primary phone number, we'll try this one next.

Driver and Owner Information

Were you driving the vehicle when the loss occurred?(Required)

Yes, I was driving the vehicle when the loss occurred.

No, I was not driving the vehicle when the loss occurred.

Please answer Yes or No.

Driver's Full Name(Required)

First Middle Last

Please provide the full name of the person driving the vehicle when the loss occurred.

Driver's Address(Required)

Street Address Address Line 2 City State ZIP Code

Please provide the mailing address for the person driving the vehicle when the loss occurred.

Driver's Date of Birth(Required)

Please provide the date of birth for the person who was driving the vehicle when the loss occurred.

Driver's License Number

Please provide the drivers' license number of the person driving the vehicle when the loss ocurred.

Driver's Primary Phone(Required)

Please provide the best contact phone number for the person driving the vehicle when the loss ocurred.

Driver's Alternate Phone

Please provide an alternate contact number for the person who was driving the vehicle when the loss ocurred.

Driver's Email Address(Required)

Please provide an email address for the person who was driving the vehicle when the loss ocurred.

Does the driver have an active auto insurance policy?(Required)

Yes, the driver has an auto insurance policy.

No, the driver does not have an auto insurance policy.

Please select Yes or No.

Driver's Auto Insurance Carrier(Required)

Please select the driver's auto insurance carrier. If you aren't sure who your insurance carrier is, contact your Auto Insurance Agent for that information.

Driver's Insurance Policy Number(Required)

Please provide the driver's auto insurance policy number in full. Refer to the drivers' carrier website to obtain the policy number if it is not known.

When the loss occurred, was the driver of the vehicle the vehicle owner?(Required)

Yes, the vehicle owner was the driver at the time the loss occurred.

No, the driver of the vehicle at the time the loss occurred is not the vehicle owner.

Please select Yes or No.

vehicleOwnerName(Required)

First Middle Last

Please enter the full name of the owner of the vehicle.

Vehicle Owner's Date of Birth(Required)

Please provide the vehicle owner's date of birth.

Vehicle Owner's Driver's License Number(Required)

Please provide the vehicle owner's driver's license number.

Vehicle Owner's Address(Required)

Same as Policyholder

Street Address Address Line 2 City State ZIP Code

Please provide the mailing address of the vehicle owner. If you, the policyholder, are also the owner of the vehicle, click the 'Same as Policyholder' tickbox to auto-fill this field from your previously-entered mailing address.

Vehicle Owner's Primary Phone Number(Required)

Please provide a contact number for the vehicle owner where we can contact them.

Vehicle Owner's Alternate Phone Number

Please provide an alternate contact number for the vehicle owner if available. If we can't reach them at the provided primary phone number, we'll try this one next.

Vehicle Owner's Email Address(Required)

Please provide the vehicle owner's email address.

Vehicle Owner's Auto Insurance Carrier(Required)

Please select the vehicle owner's auto insurance carrier.

Vehicle Owner's Auto Insurance Policy Number(Required)

Please provide the vehicle owner's auto insurance policy number here.

Passenger Information

In this section we will collect information about any passengers that were in the vehicle at the time the loss occurred, if any.

Were there any additional passengers in the vehicle at the time the loss occurred?(Required)

Yes, there were passengers present in the vehicle at the time the loss occurred.

No, there were no passengers in the vehicle at the time the loss occurreed.

I don't know.

Please select Yes, No, or I don't know.

Passenger Information

For each passenger, please provide their first and last names, contact phone numbers and email addresses.

Vehicle Information

In this section, we'll collect some information about your vehicle.

Year(Required)

Please enter the year of the vehicle.

Make(Required)

Please enter your vehicle's make (e.g. Ford, Honda, Fiat)

Model(Required)

Please enter the model of your vehicle (e.g. F-150, Civic, Fiesta)

VIN or License Plate(Required)

Please provide the vehicle's Vehicle Identification Number or your license plate.

Where is the vehicle currently located?

The vehicle is currently at a repair or service facility

The vehicle is currently at the vehicle owner's address

The vehicle is currently at the policyholder's address

The vehicle is currently at the driver's address

The vehicle is currently located at a different residence.

Please select an option.

Name of Facility(Required)

Please provide the name of the facility where the vehicle is currently located.

Facility Address(Required)

Street Address Address Line 2 City State ZIP Code

Please provide the physical address of the facility where the vehicle is currently located.

Facility's Phone Number(Required)

Please provide the service or repair facility's phone number here.

Facility's Email Address

Please provide the email address of the repair or service facility at which the vehicle is currently located.

Address of Vehicle's Current Location(Required)

Street Address Address Line 2 City State ZIP Code

Please provide the address where the vehicle is currently located.

Contact Phone(Required)

Please provide a contact phone number for the owner of the property at which the vehicle is currently located.

Contact Email

Please provide a contact email address for the owner of the property at which the vehicle is currently located.

Incident Information

In this section, we will collect details regarding the occurrence.

Date of Incident(Required)

Please select or enter the date on which the incident occurred.

Time of Incident(Required)

Please enter the time at which the incident occurred.

Street, Intersection, or Area(Required)

Please describe the location at which the incident occurred, e.g. 'Briarwood Mall South Parking Lot', 'Novi Rd. and Grand River', 'Grand River between 8 and 9 mile roads'

City(Required)

Please provide the name of the city in which the incident occurred.

State

Please select the state in which the incident occurred.

Incident Description

In this section, we will collect the details about the incident. It is crucial to answer all questions as thoroughly and completely as possible.

Were there any injuries resulting from the incident?(Required)

Yes, there were injuries.

No, there were no injuries.

I don't know

Please select Yes, No, or I Don't Know.

Injured Person(s) and Injury Information(Required)

For each injured person, please provide their First and Last Names, their address, phone number(s), email address, and the nature of the injury if able.

Did local law enforcement assist you after the incident occurred?(Required)

Yes, police assisted me after the incident occurred.

No police assistance was provided after the incident occurred.

Please select Yes or No.

Do you have a police report number for the incident?(Required)

Yes, I have a police report number for the incident

No, I do not have a police report number

You will be prompted to provide the police report number if available.

Name of the Police Agency(Required)

Please enter the name of the police or local law enforcement agency that assisted you after the incident occurred.

Police Report Number

Please provide the police report number provided to you by the assisting law enforcement officers for the incident.

Did any additional property damage occur as a result of the incident?(Required)

Yes, additional property was damaged.

No additional property was damaged.

I don't know.

Please select Yes, No, or I Don't Know.

Damaged Property & Owner Details

Please list what property was damaged and who owns the property. Provide Full Names, Addresses, Emails, and a description of the property that was damaged.

Wrapping Up

Do you have any additional information, details, questions, or concerns that you would like to add?(Required)

No, I'm ready to review my information and submit

Yes, I would like to include some additional information.

Additional Information, Details, Questions, Concerns:(Required)

Optional.