Claims Form
Type of policy
*
Commercial
Personal
Name of the person who is completing the form
*
First Name
Last Name
Insured Details
Name Insured
*
First Name
Last Name
The Insured's company name
*
Insured's Address
Company's Address
Policy Number (if known)
Insurance Carrier name (if known)
Claim Details
Date of loss
*
-
Month
-
Day
Year
Date
Time of loss
*
Hour Minutes
AM
PM
AM/PM Option
Location of Loss (address)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Type of Claim
*
Please Select
Homeowner
Auto
Type of Claim
*
Please Select
Liability
Physical damage
Cargo
Trailer interchange
General Liability
Where is the truck now?
Where is the cargo now?
Broker's Name
Broker's Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Bill of Lading?
Please Select
Yes
No
Please attach the Bill of Landing
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Commodity (if applicable)
Was the police contacted?
*
Please Select
Yes
No
Do you have a police report?
*
Please Select
Yes
No
Please attach the police report
*
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Are you at fault?
*
Please Select
Yes
No
Were there any passengers?
*
Please Select
Yes
No
Please provide a detailed description of the accident
*
Please list the passenger(s) and their full name(s), if applicable
*
Insured's Driver Details
Name of Driver
*
First Name
Last Name
Driver's Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Driver's Date of Birth
-
Month
-
Day
Year
Date
License Number
*
License Issuing State
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Year CDL was issued
Was this Driver injured during the accident?
Please Select
Yes
No
Insured's Vehicle Details
Year of Vehicle
*
Make of the Vehicle
*
VIN Number
*
Was there damage to the vehicle
*
Please Select
Yes
No
Radius of operations in miles of the insured
Please Select
0 - 50
50 - 100
100 - 300
300 - 500
unlimited
Does this claim involve another vehicle?
*
Yes
No
Claimant's Driver Details
Name of Driver
*
First Name
Last Name
Driver's Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Driver's Date of Birth
-
Month
-
Day
Year
Date
License Number
*
License Issuing State
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Year CDL was issued
Was this Driver injured during the accident?
Please Select
Yes
No
Claimant's Vehicle Details
Year of Vehicle
*
Make of the Vehicle
*
VIN Number
*
Was there damage to the vehicle?
*
Please Select
Yes
No
Radius of operations in miles
Please Select
0 - 50
50 - 100
100 - 300
300 - 500
unlimited
Describe further
Please indicate what was damaged?
*
Who should we contact?
Contact Name
*
First Name
Last Name
Contact Email
*
example@example.com
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Additional Information
Type a question
Please provide additional information or details that you would like to include in the claim such as witness information, freight broker information, etc
Please upload any helpful documents, police reports, witness statements or photos associated with loss
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