Insured Company Name
*
Who is reporting the claim?
*
Insured
Claimant
Broker
Other
Insured Company Contact Person
*
First Name
Last Name
Insured Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Who Reported the Claim?
*
First Name
Last Name
Reporting Person Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Claimant Email
example@example.com
Claim Type(s)
*
Auto Liability: Was there damages to others? (IE. cars, gates, guardrails, bridges, people, oil spills, invoices for service departments)
Motor Truck Cargo: Was there loss to the cargo explicitly? (damaged, undelivered, delayed, missing, bugs, wrong temp)
Physical Damage: Was there damage to listed units surpassing the deductible amount? (Does not cover mechanical failures, or roadside assistance)
General Liability: Was there a loss to a person or property on the insured’s premises not caused by a listed unit on Auto Liability?
What are the last 4 digits of the VIN of the truck involved?
*
Date of Incident
*
/
Month
/
Day
Year
Date of accident
Who was the driver?
*
First Name
Last Name
Description of Loss
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Auto Liability
Where did the accident occur?
Was anyone hurt?
Yes
No
Was there an oil spillage?
Yes
No
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Motor Truck Cargo
What is the date of the scheduled delivery?
*
/
Month
/
Day
Year
What damage occurred to the cargo or what was the reason for delayed delivery?
*
Was this a reefer claim?
*
Yes
No
What are the last 4 digits of the VIN of the trailer involved?
*
Was the trailer under a trailer interchange agreement?
*
Yes
No
Has the trailer interchange agreement been collected?
*
Yes
Requested
Upload trailer interchange agreement
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Upload Bill of Lading
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Is the claim submitted by broker?
*
Yes
No
Is the insured's Motor Truck Cargo coverage attached to their Auto Liability policy?
*
Yes
No
Has the insured given MIG permission to file the claim?
*
Yes
No
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Physical Damage
Where did the accident occur?
*
Was the trailer damaged?
*
Yes
No
What are the last 4 digits of the VIN of the trailer involved?
*
Was the trailer under a trailer interchange agreement?
*
Yes
No
Has the trailer interchange agreement been collected?
*
Yes
Requested
Upload trailer interchange agreement
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Was the unit towed away?
*
Yes
No
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Next
General Liability
Who was the employee involved?
First Name
Last Name
Type of damages
Property
Person
Property and Person
What were the damages?
Was anyone hospitalized?
Yes
No
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Next
Should be Empty: