Report A Claim

Claim Type

Select Claim Type*

Reporter Information

First Name*

Last Name*

Company Name*

Email*

Phone Number (xxx-xxx-xxxx)*

Role

Claim's adjuster can speak directly with the Claimant regarding the property damage portion of the claim?

Policyholder Information

Policy Number

Business Name

Insured Contact Name

Insured Email

Phone Number

Agency Name

Street Address

City

State

Zip

Country

Policyholder Driver Information

Policyholder Driver Name
Is Policyholder driver injured?

Driver License or CDL Number

Policyholder Driver Under Dispatch?

Policyholder Vehicle Information

Power Unit Information

Year

Make

Model

VIN

Vehicle Loaded or Unloaded?

Additional Information

Trailer Information

Year

Make

Model

VIN

Vehicle Loaded or Unloaded?

Other Party / Claimant Information

First Name

Last Name

Company Name

Phone Number (xxx-xxx-xxxx)

Other Party / Claimant Driver Information

Claimant Driver Name
Is Claimant driver injured?

Driver License or CDL Number
If applicable, is Claimant passenger injured?

Claimant Vehicle Information

Add more

Additional Information

Other Claimant?

Provide Additional Information

Loss Information

Accident/Injury Information

Date*

Time

:Minute

Time Zone

Accident/Injury Location

Street Address

City*

State*

Zip

Country

Loss or Accident Description*
Claim involves a fatalityEMS/Ambulance at the accident locationClaim involves a hazmat/fuel spill

Injured Employee Information

Police Department Details

Officer Name / Badge #

Case #

Citations

Comments

Upload Documents

Insured Vehicle — Bill of Lading

Insured Driver License or CDL

Claimant Driver License or CDL

Police Report, Police Photos and/or Policy Body Cam or Dash Cam

Additional Documents

Insured Driver Logbooks

Insured Vehicle Dashcam

Letter of Representation

Additional Information

Upload Documents

Additional Documents

Injured Employee Information

Name

Date of Birth

Gender

Phone Number

Job Title (Occupation)

Date of Hire

Job Status

Employee Work Location

Average Hours Worked / Week

Average Weekly Wage / Hourly Rate

Last Day Paid

Employee Sought Medical Attention?

Employee Returned to Work?

Return to Work Date

Additional Information

Upload Documents

Medical Reports

Medical Bills

Additional Documents

For NY

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

For ME, NH and RI

Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

For CA

If you are a California resident, please click on the following link for an important notice regarding the collection of Personal Information. California CCPA Notice