Please complete this form and return it to the following address:

ITR Concession Company LLC

52551 Ash Road

Granger, IN 46530

Attn: Human Resource Department

Telephone (574) 674-8836 Facsimile (574) 651-2424

 Claims may also be e-mailed to: Claims@indianatollroad.org

 

Full and complete responses to all of the requested information will assist in the investigation and processing of your potential claim.  Failure to provide all of the requested information may delay or adversely affect the investigation and processing of your potential claim.

***Claim form must be submitted within 14 days of incident to be considered ***

Name (required)

Street Address

City

State

ZIP

DL#

Email address (required)

Daytime Contact Phone Number

Vehicle Make

Model

Color

Year

Mileage

License Plate

Total amount seeking for reimbursement
$

I-Pass/EZ-Pass Transponder ID # (if applicable)

Where in your vehicle do you keep your I-Pass/EZ-Pass Transponder?

Vehicle Owner’s Name:

Owner’s Address (if different from yours)

Police Report/Incident Report #

Date Filed

Date and Time of Incident

What was your Speed?

Location of Incident (Road, Direction, & Mile Post)

Was there construction in this area?

Barricades in place?

Workers present?

If this incident involved road debris, what was the debris?

Did this incident involve a toll gate?

Describe vehicle damage:

Was anyone in your vehicle injured?

If so, identify each person who was injured and describe the injury in detail(Name/Address/Age/Injury):

Were there any witnesses to the incident?

Describe, in detail, how the incident occurred, including whether the incident was road-related; a collision with a barrier; a collision between two or more vehicles; an incident involving a toll gate or some other type of incident:

Your insurance company’s name:

Policy #:

Insurance agent’s name and address:

Please indicate the insurance you have:

Is your insurance company currently processing a claim for this incident?



Claim #:

To expedite processing, please include the following documentation in support of your claim:

Two competitive estimates from licensed repair facilities

Photographs reflecting damage to your property

Police Report—if available

Proof of Toll Road Travel (receipt or copy of transponder statement)

Please read and understand the following Certification before signing this form

I state that my answer on this form are true and correct to the best of my knowledge. I also understand that submitting this form does not indicate that ITR Concession Company has accepted responsibility for this matter, and that responsibility will be determined after further investigation and analysis of the facts and circumstances relating to the incident. I further understand and agree that I am providing the requested information voluntarily in order to assist the ITR Concession Company to investigate the incident, and that, by completing the claims form, I hereby grant my permission to the ITR Concession Company to the information contained herein and that this form and any additional information may be sent to ITR Concession Company’s insurer or others investigating the incident

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To obtain an Incident Investigation/Claim Form, click the link below, or stop in at the ITR Concession Company office. Incident Investigation/ Claim Form Opens a 19 Kb document