KBX Trailer Repair Claim

Truck Driver Information

Carrier Name

Driver Name

Driver Phone Number

Today's Date

Time

Hours

Minutes

Equipment Information

Mileage

Truck #

Trailer #

VIN #

Current Trailer Location

Description of the Problem or Damages Identified

Upload file

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?

YesNo

Purchase Order #

Accident Information

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

Officer Name

Case #

Fatality

YesNo

Citizen Injured

YesNo

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

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?

YesNoIf 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?

YesNo

Purchase Order #

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.