Section 1: Claimant Information

Name(Required)

Company (if applicable, if not enter n/a)(Required)

Address(Required)

Phone Number(Required)

Email Address(Required)

Section 2: Incident Details

Date of Incident(Required)

Time of Incdent(Required)

Location(Required)

Description of Incident(Required)

Type of Incident(Required)

Vehicle Accident

Cargo Damage

Property Damage

Other

Police Report Filed?(Required)

Yes

Report Number (enter n/a if police report was not filed)(Required)

Agency (enter n/a if police report was not filed)(Required)

Citation Number (if a citation was not received, enter n/a)(Required)

Section 3: Driver Information

Driver’s Name(Required)

Driver’s License Number(Required)

Phone Number(Required)

Vehicle Number/License Plate(Required)

Vehicle Type(Required)

Employment Status(Required)

Company Driver

Owner-Operator

Contractor

Section 4: Damages and Losses

Describe Damages (Vehicle, Cargo, or Property):(Required)

Estimated Value of Damage:(Required)

Was the Vehicle Towed?(Required)

Yes

Towing Company(Required)

Contact(Required)

Section 5: Evidence and Supporting Materials

Photos of Damages / Scene(Required)

Drop files here or

Max. file size: 10 MB, Max. files: 3.

Supporting Documents: Police Reports, Citation, Receipts, Delivery Docs(Required)

Drop files here or

Max. file size: 10 MB, Max. files: 4.

Witness 1 Name(Required)

Phone Number(Required)

Witness 2 Name(Required)

Phone Number(Required)

Section 6: Insurance Information

Insurance Provider(Required)

Policy Number(Required)

Agent Name(Required)

Agent Contact(Required)

Section 7: Additional Notes

Additional Information

Section 8: Certification & Signature

Electronic Signature (Type Your Name As It Appears On Your Government Issued I.D.)(Required)

By typing my name above, I acknowledge and agree that this typed entry constitutes my electronic signature. I understand that my electronic signature has the same legal effect and validity as my handwritten signature and that I am signing this document voluntarily. I consent to conduct this transaction electronically and agree that my typed name will be used as my legally binding signature for all purposes related to this document.

File a Claim

Section 1: Claimant Information

Section 2: Incident Details

Section 3: Driver Information

Section 4: Damages and Losses

Section 5: Evidence and Supporting Materials

Section 6: Insurance Information

Section 7: Additional Notes

Section 8: Certification & Signature