Claims Form

Claims Loss Notice

Type of Loss:

Company Name:

Reported By:

INSD/CLMNT

Return Call #:

Date:

Time:

Loss Date:

Loss Time:

Loss Location:

City:

State:

Police Called Y/N:

Fire Dept Y/N:

Hazmat Y/N:

Police Phone:

Report Number:

Responder Phone:

Citations Issued Y/N:

If Yes, Explain Citation:

Vehicles Drivable Y/N:

Tow Company:

Tow Company Phone:

Insured:

Tractor:

Trailer:

Last 6 of Tractor Vin:

Last 6 of Trailer Vin:

Tractor Damage:

Trailer Damage:

Driver:

Phone:

Injury Y/N:

Vehicle Current Location:

Insured Driver Charges:

Claimant:

Name:

Phone:

Email:

Injury Y/N:

Vehicle:

Insurance Company:

Cargo Damaged Y/N:

Type of Cargo:

Shipper:

Shipper Phone:

Receiver:

Receiver Phone:

Broker:

Broker Phone:

Cargo Location:

Cold Storage Y/N:

Costper Day:

Facts of Loss:

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