Section I. Please provide the below Broker or Freight Forwarder information with your request:

1. Name of broker or freight forwarder.
2. USDOT or MC/FF number of broker or freight forwarder
3. Surety bond or trust fund agreement account number
4. Drawdown or replenishment amount
5. Claimant(s) first and last name(s)
6. Claim number(s) (optional)
7. Surety or trust provider’s contact information

Section II.  There are 4 different reasons to report a financial responsibility drawdown, depending on the reason, please provide the corresponding information and supporting documentation, as indicated below (A-D).

1. The broker or freight forwarder consented to drawdown of available financial security to below $75,000.

1. Date the broker or freight forwarder consented to the drawdown of the security.
2. Attach security drawdown evidentiary documentation, including broker or freight forwarder consent, and dates and amounts of the claims paid.

2. The broker or freight forwarder did not respond to the provider within 7 business days or provided inadequate response to notice of a claim and the provider paid claims that reduced the security below $75,000.

1. Date the claim(s) were received.
2. Date the notice of claim(s) was sent to the broker or freight forwarder.
3. Date the broker or freight forwarder responded to the notice of claim(s) (if available).
4. Date the claim(s) were paid.
5. Attach the security drawdown evidentiary documentation including notice of claim(s), broker, or freight forwarder response, if any, and dates and amounts of claim(s) paid.

3. The financial security provider is paying a claim due to a judgment and financial security will consequently fall below $75,000.

1. Date the notification of judgment against broker or freight forwarder was received.
2. Date the payment was or will be made.
3. Date the broker or freight forwarder was made aware of this payment/claim(s).
4. Date the broker or freight forwarder responded (if available).

4. The broker or freight forwarder is experiencing financial failure or insolvency and drawdown below $75,000 is inevitable once all claims are received.

1. Date the provider became aware the broker or freight forwarder was experiencing financial failure or insolvency.
2. Date the provider notified the broker or freight forwarder of pending claim(s)
3. Is the provider reporting a drawdown in the security due to the broker’s or freight forwarder’s bankruptcy? (Yes/No)
4. Date the provider paid or will pay any claim(s)
5. Upload evidentiary documentation including why the determination of financial failure or insolvency was made.
6. Initiate electronic cancellation of the broker or freight forwarder’s financial responsibility on prescribed forms BMC-36 or BMC-85.

Section III. Reporting Replenishment of the Security

1. Provide the information listed on Section I
2. Date of replenishment.
3. Does the replenishment restore the available funds to $75,000?
4. Upload evidentiary documentation

Broker or Freight Forwarder Information

1. Name of broker or freight forwarder
2. USDOT or MC/FF number of broker or freight forwarder
3. Name of surety provider
4. Surety bond or trust fund agreement account number
5. Broker or freight forwarder contact information

Provide written evidence indicating either:

1. The notification was sent in error; or
2. The surety bond or trust fund has been restored to the required $75,000. *; or
3. Pending claims have been satisfied without the use of surety bond or trust fund. *

* FMCSA must receive verification from the surety or trust provider.