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Claims Portal
General Information
Name of person completing the form
*
Insured Name
*
Policy number (if available)
Insured Phone
*
Insured Email
*
Date of loss
*
MM slash DD slash YYYY
Time of accident (if available)
:
HH
MM
AM
PM
AM/PM
Location of Loss
Street Address
City
State
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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
MM slash DD slash YYYY
License Number
State
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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
Select files
Max. file size: 50 MB.
Email
This field is for validation purposes and should be left unchanged.
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