LDW INCIDENT FORM

In the event of damage 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.

LDW Incident Form

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 *

Trailer VIN # *

Incident Date*

Incident Time

Incident City*

Incident State *

Was the driver your employee?*

Yes

Where is the trailer located now? *

Can the trailer be moved? *

Police Report

Upload the police report if available now by clicking Choose File.

Report not yet available

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

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

Other Relevant Documents (if any)

Description of Incident *

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.