Transportation Assignment Form

Please complete and submit the following information regarding your Transportation claim assignment or email your assignment to New.Claims@RiverwoodTPA.com. You may also call in your assignment to our HOTLINE at 1.888.CUSTARD/1.888.287.8273

Your assignment will be sent to our HOTLINE for immediate processing.

Required fields are marked with *

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(Monday through Friday between 8:00AM and 5:00PM Eastern)

We are not accepting submissions with ZIP files attached at this time. You are able to select multiple files to upload with IE 10 or greater as well as Chrome, Firefox, Edge, Safari, and Opera.

Assignment City, State, and Country

City

State / Province

Country

Name

First Name*

Last Name*
Contact Information

Phone Number*

Email Address*

Cell Phone Number

Fax Number
Company

Company Name*

Branch / Office Number
Address

Address Line 1*

Address Line 2

City*

State / Province*

ZIP / Postal Code*

Country*

Name

First Name

Last Name
Contact Information

Phone Number

Email Address

Cell Phone Number

Fax Number

Policy Details

Policy Number

Policy Effective Date

Customer Claim Number
Brief Description of Loss*
Date of Loss*
Time of Loss
Location of Loss
Were Police Called?
Name of Police Dept.
Was a Ticket Issued?

Insured Person / Company*
Name

Insured First Name

Insured Last Name
Insured Address

Insured Address Line 1

Insured Address Line 2

Insured City

Insured State / Province

Insured ZIP / Postal Code

Insured Country
Contact Information

Insured Home Phone Number

Insured Email Address

Insured Cell Phone Number

Insured Work Phone Number

Vehicle Information

Vehicle Plate / Tag Number

Vehicle Make

Vehicle Model

VIN
Driver Information

Driver's First Name

Driver's Last Name

Driver's Home Phone Number

Driver's Work Phone Number

Driver's Cell Phone Number
Damage Description
Is vehicle drivable?
If not, where is the vehicle?
Injured Party Information

Injured Party First Name

Injured Party Last Name
Description of Injury(ies)

Name

Claimant First Name

Claimant Last Name
Address

Claimant Address Line 1

Claimant Address Line 2

Claimant City

Claimant State / Province

Claimant ZIP / Postal Code

Claimant Country
Contact Information

Claimant Home Phone Number

Claimant Email Address

Claimant Cell Phone Number

Claimant Work Phone Number

Vehicle Information

Vehicle Plate / Tag Number

Vehicle Make

Vehicle Model

VIN
Driver Information

Driver's First Name

Driver's Last Name

Driver's Home Phone Number

Driver's Work Phone Number

Driver's Cell Phone Number

Driver's Email Address
Damage Description
Is vehicle drivable?
If not, where is the vehicle?
Injured Party Information

Injured Party First Name

Injured Party Last Name

Injured Party Email Address
Description of Injury(ies)

Add Claimant

Name

Witness First Name

Witness Last Name
Address

Witness Address Line 1

Witness Address Line 2

Witness City

Witness State / Province

Witness ZIP / Postal Code

Witness Country
Contact Information

Witness Phone Number

Witness Email Address

Witness Cell Phone Number

Witness Work Phone Number

Policy in Force Confirmed

ZIP files will get stripped from the assignment prior to sending it to HOTLINE. You can select multiple files to upload instead as long as your browser is IE version 10 or greater, Chrome, Firefox, Safari, or Opera. To select multiple files in the File Dialog, hold the SHIFT key + mouse click to select a range of files or the CTRL key + mouse click to select individual files. Click here to learn more about selecting multiple files

Attach file(s) to this assignment
Action(s) to take / Special Instructions

EMail me a copy of this page

Transportation Assignment Form

Submitted By

Report To (if different from above)

Policy Information

Loss Information

Insured Information

Insured Vehicle Information

Claimant Information # 1

Claimant Vehicle Information # 1

Witness Information

Policy in Force