Report a Loss

ATTENTION:
If this loss involves a death, serious bodily injury, perishable cargo or diesel fuel, oil, other fluid or hazardous substance spill, please call us immediately:
888.247.4424
Are you insured by Canal?*
- Yes
- No
I am the*
I am the*
Please provide the name and telephone number for the driver of the Canal Insured vehicle:*
Please provide your contact information
Name*
First Last
Phone*
Email*
Canal Policyholder’s Company Name*
Please use the Canal Policyholder's Company Name
Policy Number / DOT number

Date of Accident?*
MM slash DD slash YYYY
Time (if available):
Where did the accident occur?*
Street Address / Highway City State
Vehicle insured by Canal:
Year
Make
Model
Vehicle Identification Number
A brief description of the accident to include:**
- • Accident details
- • Police agency name and report number
- • Witness name and phone number
Name, phone number of other party (parties) involved to include year and make of vehicles and any additional information available*
Bodily Injury
Was anyone injured?*
- Yes
- No
Did Ambulance respond?*
- Yes
- No
Name of injured Party (if available)
Property Damage (Non-Vehicle Damage)
Was other party property damaged?
- Yes
- No
Description of damage
Damage party contact information
Pollution
Was there a release of vehicle fluids or cargo?
- Yes
- No
Description of the release
Cleanup or responding authority contact information if available
Photos, Dash Cam, police reports, estimates or other documents that you would like to submit for this Loss Report
Drop files here or
Accepted file types: jpg, pdf, doc, docx, Max. file size: 25 MB.
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