LDW Incident Form

In the event of damage to, or loss of, a trailer enrolled in the Loss Damage Waiver (LDW) Program, an authorized representative of the lessee/customer MUST complete and submit the form below within 48 hours of the incident causing the damage to an enrolled trailer.

Items followed by an asterisk (*) must be completed to submit this form.

Lessee/Customer Company Name *

Contact First Name *

Contact Last Name *

Contact Phone # *

Contact Email *

Milestone Unit #

Trailer Unit # or VIN # *

Incident Date*

Incident Time

Incident City*

Incident State *

Describe incident; i.e., what happened, what caused the damages to the trailer?

Select best description of where the incident happened:

General cause(s) of damages: (Select ANY that apply)?*

Collision

Fire

Hail

Lightning

Theft

Vandalism

Windstorm

Was damage caused by collision with another vehicle?

Yes

Were there injuries or fatalities?

Yes

Was damage from trailer breakdown?*

Yes

What is driver relationship to company/lessee? *

Employee/company driver

Leased owner operator

Other

Where is the trailer located now? *

Address : *

Name of business :

Phone :

Can the trailer now be moved by truck? *

Yes

Was damaged caused by loading/unloading or forklift operation? *

Yes

Is the trailer loaded? *

Yes

Was damage caused by load shifting?

Yes

Was trailer towed to its current location? *

Yes

Was damage from hazardous materials?

Yes

Police Report
Upload the police report if available now by clicking Choose File or send it in a separate Email to Insurance@milecorp.com as soon as you receive it.

Damage Photos *
Upload damage photos by clicking Choose File or send them in a separate email to insurance@milecorp.com. with Lessee/Customer Company Name and LDW Incident Date in the Subject Line of the e-mail.
The following photos are necessary:
1. a photo of the VIN plate
2. photos of all damage
3. photos of the trailer from all sides

Note: File upload allowed limit is 2MB

Police Report #:

If the police report is not available at the time of this submission, provide the police report number.

Recovery or Towing
Include any documentation to support towing or recovery costs you incurred.

Other Relevant Documents (if any)

Other Comments

By submitting the LDW Incident Form, I affirm that I am a representative of the Lessee/Customer indicated above with authority to submit a LDW Incident Form.

LDW INCIDENT FORM

LDW Incident Form