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KBX Trailer Repair Claim
This Form is Intended for Documentation and Expedition of Repairs to KBX Trailers
PLEASE FILL OUT THE FORM BELOW WITH AS MUCH INFORMATION AS POSSIBLE.
Truck Driver Information
Carrier Name
Driver Name
Driver Phone Number
Today's Date
Time
Hours
-
12
01
02
03
04
05
06
07
08
09
10
11
Minutes
-
00
01
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AM
PM
Equipment Information
Mileage
Truck #
Trailer #
VIN #
Current Trailer Location
Description of the Problem or Damages Identified
Upload file
Drag and Drop (or)
Choose Files
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
Street Address
Apartment, suite, etc
City
State
ZIP / Postal Code
Phone
Fax
Email Address
Purchase Order Issued?
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
If there are additional injured citizens, please list their name(s), phone #(s), and email(s) here.
Witness Name
Phone
Witness Email Address
If there are additional witnesses, please list their name(s), phone #(s), and email(s) here.
Citizen Insurance Agency
Insurance Agent Name
Citizen Insurance Policy #
Upload file
Drag and Drop (or)
Choose Files
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
Street Address
Apartment, suite, etc
City
State
ZIP / Postal Code
Phone
Fax
Email Address
Purchase Order Issued?
Yes
No
Purchase Order #
IMPORTANT: KBX is not liable for payment for repairs, unless repairs are authorized by Market Express.
Contact information for Market Express:
7am-5pm Monday Through Friday Pacific Time – 503-803-4147 or 866-306-0869
After Hours weekdays, Weekends and Holidays call: 503-889-0538 Extension 115 for day dispatch. Night Dispatch: 971-352-3965
Consent
*
Yes, I agree with the
privacy policy
and
terms and conditions.
SUBMIT
Please do not fill in this field.
