Claims Portal | Reliance Partners

General Information

Name of person completing the form*

Insured Name*

Policy number (if available)

Insured Phone*

Insured Email*

Date of loss*

Time of accident (if available)

: HH

MM

Location of Loss

Street Address

City

State*

Zip

Was the police department contacted?*

Yes
No

Accident/crash report number

Briefly Describe the Accident

Was there damage to third party property or state property?*

Yes
No

Please provide a description of the damage and any information available for the other parties involved (name, phone number, insurance company name, policy number).

Were there injuries?*

Yes
No

Please provide a description of injuries.

Driver Information

Name of Driver*

Driver's Phone Number

Driver's Date of Birth

License Number

State*

Tractor Information

Year of Tractor*

Make of Tractor*

VIN of Tractor*

Was there damage to the tractor?*

Yes
No

Please provide a description of the damage to the tractor and current location of the tractor.

Trailer Information

Was there damage to the trailer?

Yes
No
Not applicable

Check this box if it was a non-owned trailer or trailer interchange

Year of Trailer*

Make of Trailer*

VIN of Trailer*

Please provide a description of the damage to the trailer and current location of the trailer.

Towing Information

Was your vehicle/trailer towed?*

Yes
No

Please provide tow company name, phone number, and address if available.

Cargo Information

Was there cargo damage?*

Yes
No

What was the cargo?*

Please provide a description of the cargo damage.

What is the current location of the cargo?

Additional Information

Please provide additional information or details that you would like to include in the claim (such as witness information, freight broker information, etc.)

Upload Files

Please upload any photos, estimates, police report information, bill of lading, etc.

Drop files here or

Max. file size: 50 MB.

Name

This field is for validation purposes and should be left unchanged.