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Cargo Theft Incident Form

GENERAL THEFT DETAILS:

Type of theft: Type of theft is a required field

Date / time of theft: Date / time of theft is a required field.

Location of theft: Location of theft is a required field

POLICE DEPARTMENT REPORTED TO:

Police Agency: Police Agency is a required field

Police Division: Police Division is a required field

Report/Occurrence No.: Report/Occurence No is a required field

VEHICLE DETAILS:

Vehicle(s): Vehicles is a required field

Year: Year is a required field

Make: Make is a required field

Model: Model is a required field

Colour: Colour is a required field

Decals: Decals is a required field

VIN/Chassis No.: VIN/Chasis No. is a required field

CARGO DETAILS:

Product Description: Product Description is a required field

Brand: Brand is a required field

No. of Pieces: No. of pieces is a required field

Container Serial No.: Container Serial No. is a required field.

INSURANCE INSURED DETAILS:

Insured's Name: Insured's name is a required field

Driver's Name: Driver's Name is a required field

Driver's License: Drivers license is a required field.

INSURANCE COMPANY DETAILS:

Insured's Claim No.: Insured's cliam no. is a required field.

Examiner Name/Phone: Examiner Name/Phone is a required field.

Documents Attached: Document attached is a required field.

Additional Comments: additional comments is a required field.

VOLUNTARY INFORMATION:

(You are not required to fill out this section.)

Your Name:

Tel.#:

E-mail:

May we contact you? Yes
No

* Information contained in this document is for the sole purpose of data collection. Whereas, the carrier, Canadian Trucking Alliance and the Insurance Bureau of Canada (IBC) do enter into an agreement to share information for the purposes of investigating motor vehicle theft and related offences, such as but not limited to conspiracy, fraud, and possession of stolen property. The information will be forwarded by secure email to an IBC analyst and subsequently forwarded to the named contact person from the respective Police Service. Any disclosure of information pursuant to this agreement shall be only for the stated purpose. There shall be no dissemination or disclosure of the information to any other agency, body or organization including but not limited to the media without prior approval.

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