Claim Submission Form
The acceptance of this form is not an admission of liability. It should be completed as fully and accurately as possible and returned immediately. You may skip questions you don't know the answers to.
Date of Loss
*
-
Month
-
Day
Year
Date
What is your role in relation to the incident?
*
(Insured) Insured by Absolute Insurance Solutions
(Claimant) Affected individual or party who sustained damage, NOT insured by Absolute Insurance Solutions
Witness, Shipper, Cargo Broker, Towing Company, Attorney, Etc.
Other
Your Company Name:
*
Your Full Name
*
First Name
Last Name
Your Email Address
*
example@example.com
Your Phone Number
*
Please enter a valid phone number.
State where incident occurred
*
Example: Indiana
Incident location address
*
Example: Mile marker 1, South Bound I-80, Mason, CA (Location description if not a specific address)
Short description of incident
*
Load, commodity info, circumstances:, weather, etc.
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Insured’s Information
Complete if available: Policyholder (Insured) with Absolute Insurance Solutions Inc
Insured's Company Name
Insured's Contact Name
First Name
Last Name
Insured's Email Address
example@example.com
Insured's Phone Number
Please enter a valid phone number.
Insured's Vehicle Details
Insured's Driver Details
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Claimant's Information
Complete if available: Individual or party sustained damage
Claimant's Company Name
Claimant's Full Name
First Name
Last Name
Claimant's Email Address
example@example.com
Claimant's Phone Number
Please enter a valid phone number.
Claimant's Vehicle Details
Claimant's Driver Details
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Authority and Towing Information
Complete if available
Police/Fire Dept Name
(if available)
Police/Fire Dept Phone Number
Please enter a valid phone number.
Police/Fire Dept Report Number
(if available)
Towing Company Name
(if available)
Towing Company Phone Number
Please enter a valid phone number.
Towing Reference / Invoice Number
(if available)
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Attachments
Please attach copies of purchase invoice(s), repair bills, valuation’s reports, BOL copies, rate confirmations, photos, etc. where applicable
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Please attach copies of purchase invoice(s), repair bills, valuation’s reports, BOL copies, rate confirmations, photos, etc. where applicable
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