NACPC PREMIUM CHASSIS

Please fill out the following form.

Chasis # *

Container #

License Plate # *

VIN #

SCAC Code *

Reporting Party *

Address

Phone

Email Address *

Name of driver involved in incident (if different from reporting party)

Date/Time of accident *

City and state where incident occurred

Please provide a brief description of the accident

Date and time police were notified

The chassis/container has been impounded by police

Upload police report (jpg, jpeg, png, pdf, doc)

The incident has been reported to your insurance company

There were witnesses to the accident

There were other vehicles involved in the accident

There were personal injuries

There were fatalities

There was a third party property damage involved

There were citations/tickets issued

The equipment was towed away

Contact Name for where the chassis is currently located

Contact Facility Address

Contact Phone Number

Contact Email