Loss and Damage Claim
Form fields: send or fax claim to, make check payable to, claimant, address, city, state, zip, reference or claim #, claim amount, claim for, shortage, damage, other, shipper, origin, consignee, destination, carrier pro #, pickup date
Briefly describe the claim and how the amount was calculated:
If the claim involve damaged goods, please check one:
__damaged goods can be replaced for approximately $_________
__damaged goods can be repaired for approximately $_________
__damaged goods are available for carrier pickup.
__damaged goods are unavailable (please explain)
Please attach the appropriate documentation:
__vendor's invoice showing price of lost or damaged goods, including final page.
__consignee's copy of the freight bill bearing loss or damage notations.
__itemized repair bill, if applicable.
__inspection report, if available
Claimant's Signature & Date: