Online Claim Report | Criterion Claim Solutions

To report a claim, please provide as much information as possible in the following several short steps. You will have an opportunity to attach any photos, police reports, or other documents at the end of the form.

All information on this page is required to move forward to the next steps of the claim process Asterisk indicates required information

Your Information

Your First Name

Please type in your first name

Your Last Name

Please type in your last name

Your Email Address

Not a valid email. For example john.doe@yahoo.com

Your Phone No.

Not a valid phone number

Your Involvement

Claimant
Agent
Insured
Other

Please indicate your involvment in the claim

Our Insured’s Information

Our Insured Our Insured’s Address
Our Insured’s City Our Insured’s State Our Insured’s Phone No.
Our Insured’s Policy # Insurance Company

Driver’s Information

Our Driver’s Name Our Driver’s Phone No. Ex: 123-123-1234
Describe Any Injuries to Driver
Maximum of 400 characters

Insured Vehicle Information

Truck / Tractor

Year / Make Last 6 #’s of VIN
Vehicle Owner’s Name Vehicle Owner’s Address
Owner’s City Owner’s State Owner’s Phone No.
Is the Vehicle Drivable?
Yes

No
Describe the Damage
Maximum of 400 characters
Where Can the Truck Be Seen?
Maximum of 400 characters

Trailer

Year / Make Last 6 #’s of VIN
Vehicle Owner’s Name Vehicle Owner’s Address
Owner’s City Owner’s State Owner’s Phone No.
Describe the Damage
Maximum of 400 characters
Where Can the Trailer Be Seen?
Maximum of 400 characters

Accident and Loss Info

Date of Accident

Time of Accident
Location of Accident

City

State
Describe the Accident
Maximum of 400 characters
Did the police respond?
Yes

No
Name of Police Dept

Police Report Number
Were there any tickets issued?
Yes

No
Who received a ticket?
Identify any witnesses or other parties involved
Maximum of 400 characters

Other Vehicle Damaged in Accident

Vehicle Owner’s Name Owner’s Address
Owner’s City Owner’s State Owner’s Phone No.
Describe the Damage
Maximum of 400 characters
Where Can the Vehicle Be Seen?
Maximum of 400 characters

Injuries

Injured Party’s Name Injured Party’s Address
Injured Party’s City Injured Party’s State Injured Party’s Phone
Describe the Injuries
Maximum of 400 characters
If there were other injured parties, please provide information in the Additional Comments section at the end of the form.

Other Property Damaged

Owner’s Name Address
City State Phone No.
Description of Property
Maximum of 400 characters
Describe Damage
Maximum of 400 characters
If there was other property damaged, please provide information in the Additional Comments section at the end of the form.

Cargo Damage

Describe the Cargo
Maximum of 400 characters
Describe the Damage
Maximum of 400 characters
Where Can the Cargo Be Seen?
Maximum of 400 characters

Shipper
- Name Address
- City State Phone No.
Receiver / Consignee
- Name Address
- City State Phone No.
Cargo Broker
- Name Address
- City State Phone No.
Towing Company
- Name Address
- City State Phone No.

Please attach Bill of Lading, Invoices, Tow Bills, or any other documents available at the end of form.

Attach Documents

Click below to attach your documents (photos, police report, or other files)

Attach a file

Additional Comments or Information

Please provide any additional comments or information

Thank you for submitting your claim online.

You will receive a confirmation email that we have received it, and your claim will receive our immediate attention.

(If you do not receive a confirmation email, please notify us immediately via email at ccs@criterionclaim.com)

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