LDW INCIDENT FORM

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

LDW Incident Form

First Name *

Last Name *

Company Name *

Contact Phone # *

Contact Email *

Trailer or VIN# *

Incident Description *

Incident Date*

Incident Time #*

Incident City*

Incident State# *

Where is the trailer located now *

Can the trailer be moved? *

Police Report (Optional) Upload police report by clicking Choose File

Damage Photos (Optional) Upload photos of damage by clicking Choose File

By clicking the “Submit Form” below, I affirm that I am a representative of the Company Name indicated above with authority to submit a LDW Incident Form.