Broker bond claim form

Please provide the following information to submit your property broker claim.

This form is intended for submission of Property Broker/Freight Broker Bond Claims only. Submission of other types of claims will result in delays and improper assignment.

Fields with an asterisk (*) are required.

Please attach the following documents:

• Signed Rate Confirmation
• Signed Proof of Delivery
• Carrier Invoice
• Broker-Carrier Agreement
• Correspondence with the broker regarding your collection efforts
• Notice of Assignment (if factoring company)

General: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act.

Click the link below to view specific fraud warnings by the following states: AL, AK, AZ, AR, CA, CO, DE, DC, FL, HI, ID, IN, KY, LA, ME, MD, MA, MN, NE, NH, NJ, NM, NY, OH, OK, OR, PA, TN, TX, VT, VA, WA or WV. If you are located in one of these states, please take time to review the appropriate warning prior to submitting your claim.

Fraud warnings

This submission form and all prior or subsequent communications and/or investigative efforts are made with the express reservation of all rights and defenses the Surety has or may have at law, equity or under the terms and provisions of the bond and/or contract documents.