Submit a Claim | Blackline Resolution Group

Section 1 — Company Information

Company Name *

DOT Number U.S. DOT number, if available

Contact Name *

Phone Number *

Email Address *

Section 2 — Claim Details

Date of Incident *

Type of Claim *

City of Incident *

State *

Brief Description of Incident *

Section 3 — Insurance Information

All fields in this section are optional. Provide whatever information is currently available.

Insurance Company Name

Claim Number

Adjuster Name

Adjuster Email / Phone

Additional Notes

By submitting this form you authorize Blackline Resolution Group, LLC to contact you regarding your claim and to act as your administrative point of contact with relevant parties. This form does not constitute legal or insurance representation.

Prefer to Speak Directly?

If you would like to speak with our team before submitting your claim, contact us directly.

claims@myblrg.com 847-637-8776