Fillable MOTOR TUCK CARGO CLAIM SUPPLEMENT (Kinsale Insurance)

Fill Online, Printable, Fillable, Blank MOTOR TUCK CARGO CLAIM SUPPLEMENT (Kinsale Insurance) Form

Use Fill to complete blank online KINSALE INSURANCE pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

MOTOR TUCK CARGO CLAIM SUPPLEMENT (Kinsale Insurance)

On average this form takes 12 minutes to complete

The MOTOR TUCK CARGO CLAIM SUPPLEMENT (Kinsale Insurance) form is 4 pages long and contains:

  • 1 signature
  • 32 check-boxes
  • 29 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Kinsale Insurance forms online.

BROWSE KINSALE INSURANCE FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Page 1 of 4
MOTOR TUCK CARGO CLAIM SUPPLEMENT
COMPLETE ONLY IF YOU HAVE EXPERIENCED MOTOR TRUCK CARGO, TRAILER INTERCHANGE OR REFRIGERATION
BREAKDOWN CLAIMS, LOSSES OR OTHER INVESTIGATIONS IN THE PAST.
ATTACH ADDITIONAL SHEETS AS NECESSARY.
ANSWER ALL QUESTIONS. If not applicable, indicate N/A.
1)
Named Insured:
Renewal? Yes No
Policy Number:
DOT Number:
MC Number:
Please attach copies of the following:
a) Currently valued five year loss runs
b) A copy of all law enforcement, NHTSA, DOT or other regulatory authority reports relevant to all claims
c) For all losses which were not covered by insurance, a copy of all demands
2) Claim Details
a. What was the date of the incident?
b. What line(s) of your coverage(s) was this claim reported on? Check all that apply:
Cargo Liability Contingent Cargo Trailer Interchange
Refrigeration Breakdown Commercial Auto - Liability Commercial Auto – Phys. Damage
Commercial General Liability Transportation Pollution Liability Other:
c. Please describe the circumstances leading up to the claim, the factual details of the incident, the commodities lost,
and steps taken following the incident to mitigate loss and evaluate the claim. Please note “attached” and include an
additional sheet if the details do not fit below:
d. If this claim is closed, did it settle before trial? Yes No
e. If this claim is open, is a hearing, trial or arbitration date set? Yes No
+ If yes, when?
f. Were any of your procedures, rules, or standard equipment changed after this incident? Yes No
APPLICANT’S INFORMATION
CLAIM INFORMATION
Kinsale Insurance Company
P. O. Box 17008
Richmond, VA 23226
(804) 289-1300
www.kinsaleins.com
Page 2 of 4
g. Was all cargo lost/the full value of the bill of lading or shipping receipt claimed? Yes No
+ If no, what percentage was lost? %
h. Total damages claimed: $
i. Claim total: $
Complete this section only for losses that were not reported to insurance
3) Loss Details
a. What was the date of the incident?
b. Why was this loss not reported to insurance? Check all that apply and describe where appropriate:
No coverage – Did not purchase insurance No coverage – Temporary lapse, had coverage before and
Outside of coverage territory after incident
Policy did not cover Trailer Interchange Policy did not cover Refrigeration Breakdown
Wanted to handle out-of-pocket to avoid Owner of cargo preferred to settle in-person outside of
reporting to carrier coverage
Loss involved excluded commodity(ies):
Loss involved excluded cause of loss:
Required policy condition was not met (protective safeguard not in place, tarps worn or absent, driver left vehicle
unattended, etc.):
Other:
c. Please describe the circumstances leading up to the loss, the factual details of the incident, the commodities lost, and
steps taken following the incident to mitigate loss. Please note “attached” and include an additional sheet if the
details do not fit below:
f. Were any of your procedures, rules, or standard equipment changed after this incident? Yes No
g. Was all cargo lost/the full value of the bill of lading or shipping receipt claimed? Yes No
+ If no, what percentage was lost? %
f. Have all suits been settled or invoices/bills paid regarding this incident? Yes No
h. What amount were you originally sued or invoiced/billed for? $
i. What amount did you pay? $
FRAUD WARNING
NOTICE TO ALABAMA, ALASKA, ARIZONA, ARKANSAS, CALIFORNIA, CONNECTICUT, DELAWARE, GEORGIA, IDAHO, ILLINOIS, INDIANA,
IOWA, KANSAS, MARYLAND, MASSACHUSETTS, MICHIGAN, MINNESOTA, MISSISSIPPI, MISSOURI, MONTANA, NEBRASKA, NEVADA,
NEW HAMPSHIRE, NORTH CAROLINA, NORTH DAKOTA, OREGON, RHODE ISLAND, SOUTH CAROLINA, SOUTH DAKOTA, TEXAS, UTAH,
VERMONT, WASHINGTON, WEST VIRGINIA, WISCONSIN, AND WYOMING APPLICANTS: In some states, any person who knowingly, and
with intent to defraud any insurance company or other person, files an application for insurance or statement of claim containing any
LOSSES OUTSIDE OF COVERAGE
Page 3 of 4
materially false information, or, for the purpose of misleading, conceals information concerning any fact material thereto, may commit a
fraudulent insurance act which is a crime in many states.
NOTICE TO COLORADO APPLICANTS: It is unlawful to knowingly provide false, incomplete or misleading facts or information to an
insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines,
denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete
or misleading facts or information to a policy holder or claimant for the purpose of defrauding or attempting to defraud the policyholder
or claiming with regard to a settlement or award payable for insurance proceeds shall be reported to the Colorado Division of Insurance
within the Department of Regulatory Agencies.
NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: WARNING: It is a crime to provide false or misleading information to an insurer for the
purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny
insurance benefits if false information materially related to a claim was provided by the applicant.
NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud or deceive any insurance company files a
statement of claim containing any false, incomplete or misleading information is guilty of a felony of the third degree.
NOTICE TO HAWAII APPLICANTS: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for
payment of a loss or benefit is a crime punishable by fines or imprisonment, or both.
NOTICE TO KENTUCKY APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or other person files
an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning
any fact material thereto commits a fraudulent insurance act, which is a crime.
NOTICE TO LOUISIANA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or
knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in
prison.
NOTICE TO MAINE APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company
for the purpose of defrauding the company. Penalties may include imprisonment, fines, or denial of insurance benefits.
NOTICE TO NEW JERSEY APPLICANTS: Any person who includes any false or misleading information on an application for an insurance
policy is subject to criminal and civil penalties.
NOTICE TO NEW MEXICO APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or
knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal
penalties.
NOTICE TO NEW YORK APPLICANTS: Any person who knowingly and with intent to defraud an insurance company or other person files an
application for insurance or statement of claim containing any materially false information, or conceals, for the purpose of misleading,
information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and shall also be subject to a civil
penalty not to exceed $5,000 and the stated value of the claim for each such violation.
NOTICE TO OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer,
submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
NOTICE TO OKLAHOMA APPLICANTS: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer,
makes a any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
Page 4 of 4
NOTICE TO PENNSYLVANIA APPLICANTS: Any person who knowingly and with intent to defraud any insurance company, or other person,
files an application for insurance or statement of a claim containing any materially false information or conceals for the purpose of
misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects the person
to criminal and civil penalties.
NOTICE TO TENNESSEE APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance
company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
NOTICE TO VIRGINIA APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company
for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
The Applicant acknowledges that the answers provided herein are based on a reasonable inquiry and/or investigation. The Applicant
warrants that the above statements and particulars together with any attached or appended documents are true and complete and do
not misrepresent, misstate or omit any material facts.
The Applicant agrees to notify us of any material changes in the answers to the questions on this questionnaire which may arise prior
to the effective date of any policy issued pursuant to this questionnaire and the Applicant understands that any outstanding
quotations may be modified or withdrawn based upon such changes at our sole discretion.
Completion of this form does not bind coverage. Applicant’s acceptance of the company’s quotation is required prior to binding coverage
and policy issuance.
All written statements and materials furnished to the company in conjunction with this application are hereby incorporated by reference
into this application and made a part of this application.
Applicant: Title:
FEIN #:
Applicant’s Signature: Date:
Agent/Broker Name:
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

MOTOR TUCK CARGO CLAIM SUPPLEMENT (Kinsale Insurance)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 31 January 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document