Name:

Company:

Address:

Telephone:

Fax:

Mobile phone:

Reports to:

Name:

Claim number:

Address:

Home telephone:

Work telephone:

Mobile phone:

Note: most equipment is picked up by an 18-wheeler.

Is a dock available: yes no

If not, is there a person to help load the equipment? yes no

Equipment ready for pickup on: (date)

Where equipment is located: insured company other

Company name:

Address:

Contact person:

Telephone:

List all damaged equipment:

Special instructions:

Please print a copy of this form for your records. If you have difficulty submitting the form via e-mail, please display the printable form, then print and fax it separately.