TIA Claim Form

Claim Form
Click to view TIA CLAIM SUBMISSION FAQ
- Claimant Company Name
- Claimant Company Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip CodeCountry
- Claimant Contact Name
  
  First NameLast Name
- Claimant Phone No.
  Please enter a valid phone numberFormat: (000) 000-0000.
- Claimant Email
  example@example.com
- Trustor/Principal Company Name
  Broker you are filing the claim against
- Trustor/Principal Company Address
  
  Street Address
  
  Street Address Line 2
  
  CityState
  
  Zip Code
- Trustor/Principal Contact Name
  
  First NameLast Name
- Trustor/Principal Phone No.
  Please enter a valid phone numberFormat: (000) 000-0000.
- Please list commodities related to the claim
- Did the commodity cross state lines?
- Is this commodity refrigerated?
- Claimant's Invoice #(s)
  You may use one form for multiple invoices
- Claim Amount
- Date Reported to Avalon
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate claim was submitted
- Date of Loss
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearEarliest pickup date in your rate confirmation
- Policy Effective Date
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearBond Effective Date
- Trust/Bond #
  This information is available by searching the Broker's MC# or DOT #
- Trustor/Principal MC #
  If unknown, you may search the FMCSA database by the Broker's name and state they are located in.
- Copy of the following required
- Billing Invoice File Upload
  
  Allowed file types: pdf, doc, docx, xls, xlsx, csv, png
  Cancelof
- Rate Confirmation File Upload
  
  Allowed file types: pdf, doc, docx, xls, xlsx, csv, png
  Cancelof
- Bill of Lading File Upload
  
  Allowed file types: pdf, doc, docx, xls, xlsx, csv, png
  Cancelof
- Carrier Authority File Upload
  
  Allowed file types: pdf, doc, docx, xls, xlsx, csv, png
  Cancelof
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