Claim Form - Transit Name of Insured(Required) Phone NumberEmail Date of Loss(Required) DD slash MM slash YYYY Description of Incident Departure Date DD slash MM slash YYYY Estimated Date of Arrival at Desitnation DD slash MM slash YYYY Freight in transit from (Please provide town and state): Freight transit to (Please provide town and state): Where is the freight now? Please provide details of depot / storage facility, town name and state: Please provide contact name and phone number at location: Freight DamagedFreight DescriptionQuantityInvoice ValueReplacement Cost Add RemoveName of Driver First Last Driver's Phone NumberDriver's Email Drivers Date of Birth DD slash MM slash YYYY Driver's Licence No State of Issue Class Was the vehicle driven with the insured’s consent? Yes No If No, further details will be requiredWas the freight being handled or controlled with the insured’s consent? Yes No If No, further details will be requiredWas any intoxicating liquor or drugs (including prescription drugs) consumed in the 12 hours preceding the accident or transit journey? Yes No If Yes, further details will be requiredDid the driver or person in control of the freight undergo a breathalyser / blood test? Breathalyser Blood Test Both Breathalyser & Blood Test If Yes, further details will be requiredVehicle Details - Year, Make & Model Registration VIN Trailer Details - Year, Make & Model Registration VIN Was another vehicle/person involved? Yes No If yes, please provide further informationName First Last PhoneEmail Vehicle Details - Year, Make & Model Registration Drivers Licence No State of Issue Class Checklist of Important Documents Copy of consignment note including terms and conditions on reverse side. Packing list / inventory / document manifest. Quotation for replacement / repairs / reconditioning of freight or items claimed. Log book. Licence (front and back). Invoices for purchases or sale of goods. Driver statement signed and dated (What happened? Where? Cause and why? Comment on cargo loss damage and salvage). Delivery receipts / documents (obtained during various parts of transit journey). Specific instructions or agreements relating to the freight handling, transit, delivery, etc. ALL different terms and conditions of carriage / storage / cargo issued (if more than one subcontractor / principal). Copy of non-delivery / shortage receipt / credit notes if applicable. Copy of temperature records if applicable. Weight certificates or other evidence of type and state of goods prior to / at commencement of carriage. Survey report on freight (prior or post transit). Any other documentation that you think may assist us in understanding or defending your claim against another party. Additional InformationConsent(Required) I/We declare that the whole of the above information and answers are true in every detail and no information has been withheld.Name(Required) First Last Date(Required) DD slash MM slash YYYY File Drop files here or Select files Accepted file types: png, jpg, pdf, doc, docx, Max. file size: 16 MB. CAPTCHA
