File a Claim

Party Filing Claim:(select one)*

Contact Name:*

First Last

Contact Company Name:*

Contact E-mail:*

Contact Telephone:*

Claimants Information:

Claimants Name:

First Last

Claimants Company Name:*

Claimants E-mail:

Claimants Telephone:

Date of Incident, Loss or Damage:*

State where loss occurred*

Describe the incident, cause, nature of the loss:*

Commodity Description:*

Claim Type:*

Suit Type:

Suit Details:

Please provide any legal suit details available.

Policy Number (Certificate #):

Internal Reference Number:

Load Number, Internal Tracking Number, Insured specific file number - to be referenced for claim file

Shipment State of origin:

Origin Country:

Shipment Destination State:

Destination Country:

Deductible:

Claim Amount:*

Transit Type:

Transit Mode:

Motor Carrier Company Name:*

MC Number:

UPLOAD documents to Expedite:

Drop files here or

Max. file size: 50 MB.

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