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KBX Trailer Repair Claim

This Form is Intended for Documentation and Expedition of Repairs to KBX Trailers

Please complete all fields with as much detail as possible.

Please note:

Response times may be delayed around national holidays.
If you do not receive a response within one hour, treat the situation as “afterhours” and follow your company’s repair process.
Whenever possible, use Tec Equipment- our preferred maintenance provider. Their gated facilities are open from 7 a.m. to 5 p.m.

"*" indicates required fields

Phone

This field is for validation purposes and should be left unchanged.

Truck Driver Information

Carrier Name

Driver Name*

Driver Phone Number*

Today's Date

MM slash DD slash YYYY

Time

Hours

:

Minutes

AM/PM

Timezone*

Eastern

Central

Mountain

Pacific

Mileage

Truck #

Trailer #

VIN #

Current Trailer Location*

Description of the Problem or Damages Identified

Do you plan to wait or are you able to proceed with travel?

Wait

Proceed

Next/Final Destination

Upload File

Drop files here or

Max. file size: 8 MB.

Please upload any images of problem or damages

Towing Information

If there is no towing information, you may skip this section.

Towing Company Name

Towing Contact Name

Address

Street Address Apartment, suite, etc City State ZIP / Postal Code

Phone

Fax

Email Address

Purchase Order Issues?

Yes

No

Purchase Order

Accident Information

If there is no accident information, you may skip this section.

Officer Name

Case #

Fatality

Yes

No

Citizen Injured

Yes

No

Citizen Name

Phone

Citizen Email Address

Additional injured citizens

If there are additional injured citizens, please list their name(s), phone #(s), and email(s) here.

Witness Name

Phone

Witness Email Address

Additional witnesses

If there are additional witnesses, please list their name(s), phone #(s), and email(s) here.

Citizen Insurance Agency

Insurance Agency Name

Citizen Insurance Policy #

File

Drop files here or

Max. file size: 8 MB.

Please upload any images of damage you are reporting

Maintenance

If there is no maintenance information, you may skip this section and submit your form at the bottom of this page.

Have you contacted someone to repair the issues?

Yes

No

If yes, please fill in the remaining fields.

Maintenance Company Name

Maintenance Contact Name

Address

Street Address Apartment, suite, etc City State ZIP / Postal Code

Phone

Fax

Email Address

Purchase Order Issue?

Yes

No

Purchase Order #

PRE-TRIP INSPECTION

Before you leave, check the trailer for any problems. If you find something wrong, fill out this form. If it is between 7am and 5pm CST on a weekday, we will get back to you soon. If not, call your company for help. If you have a breakdown or an accident, follow your company’s rules and call the police if needed. Make sure the trailer is in a safe place. You are responsible for what happens to the trailer until you deliver the load. Your company must pay for any damage that happens on the way. By filling out this form, you agree to our privacy policy and terms and conditions.

PRE-TRIP DAMAGES/REPAIRS

If damage or repairs are spotted on the pre-trip inspection before you leave the shipping location, documentation is important. If it is after the weekday hours of 7am – 5pm central standard time, contact your company for assistance. Otherwise submitting this during these weekday hours, a person will answer you in a timely manner by your contact information submitted. If this is a breakdown or accident, follow your company policy to contact authorities as directed by your company after submitting this form. Do everything to assure that the vehicle is in a safe location to avoid any person injury to you, or others involved.

POST DROP-OFF

After you leave with the trailer the shipping location, the carrier is required to do the repairs necessary to deliver the load safely to the destination. The carrier is responsible for any damage that occurs during that time as per signed Carrier – KBX Interchange agreements. The trailer is to be delivered to its destination in the same condition as it leaves.

LIABILITY

KBX IS NOT LIABLE FOR PAYMENT UNLESS REPAIRS ARE DOCUMENTED BY PICTURES AND DETAILS SUBMITTED ON THIS FORM. Repairs will be considered for payment only if the repairs needed were identified prior to driver moving the trailer. Please submit as much detail as possible is a benefit to clarify the time/ date damage occurred or was verified. This will help all parties understand who is responsible for charges.

Consent*

Yes, I agree with the privacy policy and terms and conditions.

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:

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