Damage Claim Report
Premier Warehousing / Rogers-Premier Enterprises. Complete one form per incident. Questions: Incident & Claims Reporting (800) 448-6230 Ext. 2015. Please upload damage photos and any repair invoice using the upload field below.
1. Carrier
*
2. Driver's name
*
3. Contact phone
*
4. Contact email
*
5. Facility location
*
6. Tractor #
*
7. Trailer #
*
8. Invoice #
*
9. Date of damage
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
10. Time of damage (e.g. 2:30 PM)
*
11. Estimated cost of damage (USD)
*
12. Damage involves
*
Freight
Equipment
13. Type of damage
*
Straps
Tarps
Winches
Tires
Lights
Rubrail
Landing gear
Headboard
Gladhands
Other
14. Description of damage (please be specific)
*
15. Location of damage (select all that apply)
*
Tractor front
Tractor driver side
Tractor passenger side
Tractor rear
Trailer front
Trailer driver side
Trailer passenger side
Trailer rear doors
Trailer roof
Undercarriage
Landing gear area
Other
16. Were tarping/yard management staff notified upon finding damage?
*
Yes
No
17. Were pictures taken?
*
Yes
No
Upload photos of the damage and any repair invoice (optional)
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18. I certify this information is true and complete.
*
I certify
19. Type your full name as your electronic signature
*
Submit
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