Online Claim Reporting Services INSUREDCompany Contact Address PhoneFaxEmail CLAIMANTIndividual/Employee Employee ID Contact (if other than claimant) Relationship Address PhoneFaxEmail ACCIDENTDate of Loss (MM/DD/YYYY) MM slash DD slash YYYY Location (City and State) Person(s) Involved (Passengers, etc.) If Derailment (How many cars involved) Leak (Yes/No) Yes No Evacuation (Yes/No) Yes No Type of Injury Witness(es) (Name, Address, and Phone) Accident DescriptionPhoneThis field is for validation purposes and should be left unchanged.
