File an Insurance Claim

If you need to report an accident or incident involving one of our insured parties, please complete the form below with as much detail as possible. This information will help our team review your claim quickly and begin the claims process.

After submitting the form, you will receive a Claim Reference Number. Please keep this number for your records, as it will help us track and process your claim efficiently.

If you have any immediate questions regarding your claim, please contact our office directly.

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Date of the Loss

Date the accident or incident occurred.

Claim Filer's Email Address *

Who is filing the claim? *InsuredClaimant

Insured Name *

First

Last

Insured Information — complete this section if you are the insured.

Insured Address *

Insured Contact Name

Insured Phone Number *

DOT #

Claimant Name *

First

Last

Claimant Information — complete this section if you are the claimant.

Claimant Address *

Claimant Contact Name

Claimant Phone Number *

Accident Information

Location / Address where accident occurred *

Accident Information

Brief description of the accident *

Insured Truck Information

Carrier Name *

Policy Number

Driver Name *

First

Last

Truck Year

Truck Make

VIN #

Driver Phone Number

Police Report

Was a police report filed? *YesNo

Police Report

Upload Police Report

Drag & Drop Files, Choose Files to Upload You can upload up to 15 files.

Click or drag a file to this area to upload. Max file size is 30MB.

Other Party Involved Information

Name of the Driver

First

Last

Insurance Provider

Policy Number

Other Party Involved - Driver Phone Number

Vehicle Year

Vehicle Make

Vehicle VIN Number

Information about any other parties involved

Photos

Upload Photos of the Accident

Drag & Drop Files, Choose Files to Upload You can upload up to 15 files.

Click or drag files to this area to upload. You can upload up to 15 files. Max file size is 30MB.

Witness Information

Witness Name

Witness Information

Witness Phone Number

Name Name Information

Witness Email

SubmitSave and Resume Later