PHYSICAL DAMAGE CLAIM -
Complete all fields
Insured's Name
Contact Name
Date of Loss
Time of Loss
Location of Loss (City & State)
Authorities Contacted?
Yes
No
Accident Report Issued?
Yes
No
Driver Name
Phone
Driver's Address
Select Type of Driver
Owner Operator
Company Vehicle
Tractor Year, Make & Serial #
Loss Payee (if damaged)
Trailer Year, Make & Serial #
Loss Payee (if damaged)
Location of Where Unit Can Be Seen
Contact Name & Phone of Where Unit Is
Description of Loss
Towing Company & Phone
Towing Company Address
Reported By (Your Name)
Turner & Hamrick, LLC 2002
