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Claim Form

Form to Submit to Fulmont. There are three ways you can send it to us:
  • Fill in the on-line form below and press "Submit Form".
  • Download our PDF printable form, fill in and mail it to:
    Fulmont Mutual Insurance Company
    P.O. Box 487, Johnstown, NY 12095-0487

    or fax it to: 518-762-7870

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Fulmont Mutual Insurance Company


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Producer -
   

Contacts email:

Today's date:

Producer's name:

Producer's address:

Phone number:

Date of loss:

Time of loss (include .am or .pm):

Policy number:

Policy effective date:

Policy expiration date:

   
Insured -
 

Insured's name:

Insured's address:

Insured's home phone number:

Insured's business phone number:

Person to contact:

Contact's daytime phone number:

   
Loss -
 

Location of loss:

Kind of loss (fire, wind, explosion, etc.)

Description of loss & damage:

Probable amount of entire loss:

   
Injured/Property Damage -
 

Name of injured/owner party:

Address of injured party:

Phone number of injured party:

Date of birth of injured party:

Sex of injured party:

Occupation of injured party:

Employer's name of injured party:

Employer's address of injured party:

Employer's phone number of injured party:

Describe what injured was doing and injury:

Where was the injured taken:

Describe property damaged:
 

Where can property be seen:

Estimate amount:

   
Witnesses-
 

Witness#1 name:

Witness#1 address:

Witness#1 home phone number:

Witness#1 home business number:

Witness#2 name:

Witness#2 address:

Witness#2 home phone number:

Witness#2 home business number:

Miscellaneous Information:

 
WE ARE REQUIRED BY LAW TO ADVISE YOU THAT, "Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, AND SHALL ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION"
   

Reported by:

Reported to:

Signature of producer or insured:

   
   

     

Main Menu:
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For further information regarding our policies, send e-mail to
info@fulmontmutual.com, or write to us at:
Fulmont Mutual Insurance Company
P.O. Box 487, Johnstown, NY 12095-0487

Copyright Fulmont Mutual Insurance Company. All rights reserved.
This web site was developed by Empire Web Pages on June 07, 1997.
This page was most recently updated on October 20, 2013.

 

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