Claims - Links Insurance

CLAIM FORM - LINKS INSURANCE SERVICES, INC.

6200 Village Parkway, Suite #203, Dublin, CA 94568 Phone: 925-361-5185 . Fax: 925-556-1636

Date of Loss:

Time Approx:

Today’s Date:

( Fields in BOLD / Red must be Filled to set up a claim.)

Our Customer Information

Insured:

Contact Name & Phone:

Truck

( VIN # last 5 digits ) in Accident / Hauling Load - See Notes

Year and Make:

Damaged--

Yes

Trailer

( VIN # last 5 digits )

Year and Make:

Damaged--

Yes

Loss Location:

(Hwy or Ave)

Nearest City:

State:

Police Report / Case #:

Police Officer Name / ID / Phone:

Driver

Name:

Lic #:

State Issued:

Date Of Birth:

Phone #:

Date Of Hire:

Towing Company:

Contact Form & Phone:

Present Location of Damaged Vehicle:

What happened (Do Not Leave Blank)

For Cargo Claims -- Reason for Load Rejection | Commodity Hauled

Reefer

Dry

Other Party / Claimant Info

Injuries:

YesNo

Name:

Ph:

Email/Fax:

Driver Name:

Lic#:

DOB:

Phone#:

Name of Ins Co:

Claim#:

Policy#:

Ph#:

Fax:

Email:

WITNESS INFORMATION: ( Attach Witness Statement if available):

Name:

Ph:

Email/Fax:

Notes

1:Liability --There is damage to other vehicle, person or property
2:Physical Damage --Damage to your Truck or Trailer or Theft ( Police Report Must in Theft case)
3:Cargo- Documents needed Bill of Lading Load Inspection Report Reefer maintenance documents;

Commodity Hauled, Product location; Temperature download
4. Attach Police Report if possible
5:( Attach Signed Driver Statement if possible) - Must fill How the accident happened
6:Truck VIN # needed for Cargo/ Reefer claims too :Date of Accident / Loss is Date Cargo Delivered / Damaged

I certify under penalty of perjury under the laws of the United States of America that the above information is true and correct.

SIGNATURE

Name of the person filling the Form