Insurance Claim Form Insurance Claim Form Please fill out this form to submit your insurance claim. Fields marked with * are required. Personal Information First Name Last Name Email Address Phone Number Street Address City State/Province Zip/Postal Code Insurance Information Policy Number Type of Insurance -- Select Insurance Type -- Trucking Insurance Auto Liability Insurance Motor Truck Cargo Occupational Accident Coverage Non-Trucking Liability and Bobtail Insurance General Liability Insurance Physical Damage Truck Insurance Excess or Umbrella Insurance Freight Broker Insurance Borderless Coverage Commercial Insurance Risk Management Usage Based Solutions Additional Coverage Types (select all that apply) Trucking Insurance Auto Liability Motor Truck Cargo Occupational Accident Non-Trucking Liability General Liability Physical Damage Excess/Umbrella Freight Broker Borderless Coverage Commercial Insurance Risk Management Usage Based Claim Details Date of Incident Location of Incident Description of Incident Description of Damage/Loss Estimated Cost of Damage/Loss $ Additional Information Police Report Filed? Yes No Police Report Number Were there any witnesses? Yes No Witness Contact Information Document Upload Upload Photos of Damage Click to upload or drag and drop PNG, JPG, GIF (Max 10MB) Upload Supporting Documents Click to upload or drag and drop PDF, DOC, XLS (Max 10MB) Submit Claim
