EnglishEn españolMYTHS ABOUT REPORTING A CLAIM 1Detalles del Accidente2Datos de Contacto del Reclamante 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:888.247.4424Eres la persona asegurada por Canal?* Sí No Yo soy el *Relación con el AseguradoInsuredInsured's AttorneyInsured's DispatcherInsured DriverEmployeeInsured's FriendInsured's Insurance AgentInsured's RelativeI am the*Relationship to InsuredOther Vehicle DriverOther Vehicle OwnerOther Vehicle Owner's Insurance AgentOther Party's AttorneyOther Vehicle Owner's RelativePlease provide the name and telephone number for the driver of the Canal Insured vehicle:*Por Favor facilite su informacíon de contactoName* First Last Teléfono*Correo Electrónico* Persona / Nombre de Empresa*Please use the Canal Policyholder's Company NameNúmero de Póliza / Número DOTCuando ocurrío el accidente?* MM barra DD barra AAAA Time (if available):Where did the accident occur?* Street Address / Highway Ciudad AlabamaAlaskaSamoa AmericanaArizonaArkansasCanadaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaIslas Marianas del NorteOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahIslas Vírgenes de los Estados UnidosVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific Provincia Vehículo asegurado por Canal:AñoMarcaModeloNúmero de identificacion del vehículoUna breve descripcíon del accidente, incluyendo informacion sobre lesiones.*• Accident details• Police agency name and report number• Witness name and phone numberName, phone number of other party (parties) involved to include year and make of vehicles and any additional information available*Bodily InjuryWas anyone injured?* Yes NoDid Ambulance respond?* Yes NoName of injured Party (if available)Property Damage (Non-Vehicle Damage)Was other party property damaged? Yes NoDescription of damageDamage party contact informationPollutionWas there a release of vehicle fluids or cargo? Yes NoDescription of the releaseCleanup or responding authority contact information if availableFotos, informes policiales, estimaciones o otros documentos que le gustaría presentar para este reporte de pérdida Suelta archivos aquí o Selecciona archivosTipos de archivos aceptados: jpg, pdf, doc, docx, Tamaño máximo de archivo: 25 MB.CAPTCHA
