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AUTO LOSS CLAIMS

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Auto Loss Claims Form
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CARGO LOSS CLAIMS FORM

Claim Reporting Instructions

1. Complete as much of the questionnaire as possible.
2. Leave the information you do not have blank.
3. Send any additional information or documents related.
4. Fax or email additional pages (if applicable) to 714-546-4457 or Claims@RSI-Ins.com. Please use a cover page and put attention Claims Dept.

Information

Policy # *

Load Of *

Date Load Picked Up *

Pick Up

Business Name *

Address *

Phone *

Contact Name *

Delivery

Business Name *

Address *

Phone *

Contact Name *

Cargo Loss Information

Date Load Delivered or Damaged *

Insured Driver Name *

Tractor Year *

Make *

Last Vin # *

Was Load Sealed? *

Description of Damage or Reason for Refusal *

Estimated Amount of Claim if Available

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