Webform The Missouri Department of Transportation (MoDOT) is committed to an efficient claims process. We will thoroughly investigate the facts surrounding this incident and expedite the processing as quickly as possible. Note: Submission of this form does not guarantee MoDOT acceptance of liability or responsibility and is merely for fact finding and verification purposes. The use of non-original equipment or aftermarket wheels and/or tires could possibly exclude you from eligibility for compensation from MoDOT. If compensation is paid, only components directly damaged from the incident will be considered. You will receive a confirmation of submission by email. This confirmation will contain the information submitted with your claim and can be printed for your records. Have a question about the process? See our Frequently Asked Questions. General Information Claimant Name: First Name:* Last Name:* Address Street 1* Street 2 City/Town* State/Province* - Select -AlabamaAlaskaAlbertaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle EastArmed Forces AmericasArmed Forces PacificBritish ColumbiaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederate States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineManitobaMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNewfoundland and LabradorNew Brunswick New HampshireNew JerseyNew MexicoNew YorkNorthwest Territories North CarolinaNorth DakotaNorthern Mariana IslandsNova Scotia NunavutOhioOklahomaOntarioOregonPalauPennsylvaniaPrince Edward Island Puerto RicoQuebecRhode IslandSaskatchewanSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingYukon ZIP/Postal Code* Email Address* Phone Number* Who is Filing this Claim? Who is Filing this Claim? The Person or Party who was Injured or Experienced Property Damage Insurance Company Attorney Parent / Legal Guardian Other… Enter other… What Happened? Date of Incident* Time of Incident:* Incident Description: Please describe in detail the incident / event, including what occurred immediately before and after: Please include the following items in your details: Roadway you were on, direction you were traveling, what caused damage to your vehicle Damage Description: Please describe the injury or property damage directly resulting from this incident/event: Where Did this Incident / Event Occur? County Where Accident Occurred* - Select -AdairAndrewAtchisonAudrainBarryBartonBatesBentonBollingerBooneBuchananButlerCaldwellCallawayCamdenCape GirardeauCarrollCarterCassCedarCharitonChristianClarkClayClintonColeCooperCrawfordDadeDallasDaviessDeKalbDentDouglasDunklinFranklinGasconadeGentryGreeneGrundyHarrisonHenryHickoryHoltHowardHowellIronJacksonJasperJeffersonJohnsonKnoxLacledeLafayetteLawrenceLewisLincolnLinnLivingstonMaconMadisonMariesMarionMcDonaldMercerMillerMississippiMoniteauMonroeMontgomeryMorganNew MadridNewtonNodawayOregonOsageOzarkPemiscotPerryPettisPhelpsPikePlattePolkPulaskiPutnamRallsRandolphRayReynoldsRipleySalineSchuylerScotlandScottShannonShelbySt. CharlesSt. ClairSt. FrancoisSt. GenevieveSt. LouisSt. Louis CityStoddardStoneSullivanTaneyTexasVernonWarrenWashingtonWayneWebsterWorthWright Incident Location: Interstate / Highway / State Route / Street Name* Cross Street | Mile Marker | Exit Number City/Town* State/Province* - Select -AlabamaAlaskaAlbertaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle EastArmed Forces AmericasArmed Forces PacificBritish ColumbiaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederate States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineManitobaMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNewfoundland and LabradorNew Brunswick New HampshireNew JerseyNew MexicoNew YorkNorthwest Territories North CarolinaNorth DakotaNorthern Mariana IslandsNova Scotia NunavutOhioOklahomaOntarioOregonPalauPennsylvaniaPrince Edward Island Puerto RicoQuebecRhode IslandSaskatchewanSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingYukon ZIP/Postal Code Latitude: Longitude: Signature:* I affirm, under penalty of law, that the statements I have made herein are correct and truthful and understand and agree that I can be prosecuted for making a false statement to a governmental entity. I also understand and agree that by entering my name below, I am electronically signing this claim form and intend that my electronic signature shall have the full legal force and effect as my written signature. Date Signed:* Upload File(s): 10MB Upload Limit Allowed File Types: gif jpg png bmp eps tif pict psd txt rtf pdf avi mov mp4 svg tar zip If you have additional files to submit but cannot due to file size restrictions, you can present those after initial contact is made. Claimant Name Location of Incident Date & Time of Incident Date & Time of Incident: Date Date & Time of Incident: Time Some of the above fields are required and indicated by an asterisk. If your claim is successfully submitted, you will receive a popup, stating it was successful. Leave this field blank
