Trucking Insurance Claim

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Insured Company Name
Insured Company Name
Who is reporting the claim?
- Insured
- Claimant
- Broker
- Other
Insured Company Contact Person
First Name Last Name
Insured Phone Number
Insured Phone Number
Claimant Name
First Name Last Name
Claimant Phone Number
Claimant Phone Number
Claim Type(s)
- Auto Liability
- Motor Truck Cargo
- Physical Damage
- General Liability
Claim Type Definitions: (1) Auto Liability - Was there damages to others? (IE. cars, gates, guardrails, bridges, people, oil spills, invoices for service departments); (2) Motor Truck Cargo - Was there loss to the cargo explicitly? (damaged, undelivered, delayed, missing, bugs, wrong temp); (3) Physical Damage - Was there damage to listed units surpassing the deductible amount? (Does not cover mechanical failures, or roadside assistance); (4) General Liability - Was there a loss to a person or property on the insured’s premises not caused by a listed unit on Auto Liability?
What are the last 4 digits of the VIN of the truck involved?
What are the last 4 digits of the VIN of the truck involved?
Date of Incident
Month
Day
Year
Who was the driver?
First Name Last Name
Description of Loss
Description of Loss
Please do not include sensitive, private information in this area.
This field is for validation purposes and should be left unchanged.
This field is for validation purposes and should be left unchanged.