KBX Trailer Repair Claim

Truck Driver Information

Carrier Name

Driver Name *

Driver Phone Number *

Today's Date

Time

Hours

Minutes

Time Zone *EasternCentralMountainPacific

Equipment Information

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? *WaitProceed

Next/Final DestinationThis information is necessary so the representative can set up repair in your direction of travel

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 #

FatalityYesNo

Citizen InjuredYesNo

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 #

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.

Time

Hours

Minutes

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.