Loss And Damage Claim Form printable pdf download

Loss And Damage Claim Form

Loss and Damage Claim

SEND OR FAX CLAIM TO:

MAKE CHECK PAYABLE TO:

CLAIMANT

ADDRESS

CITY, STATE, ZIP

CLAIMANT'S NAME

DATE

REFERENCE OR CLAIM #

CLAIMANT'S TELEPHONE NO.

CLAIMANT'S FAX NO.

CLAIMANT'S ADDRESS

CITY, STATE, ZIP

CLAIM AMOUNT

CLAIM FOR

__ Shortage

__ Damage

__ Other (specify):

SHIPPER

CONSIGNEE

ORIGIN

DESTINATION

CARRIER PRO # or ATTACH A COPY OF THE BILL OF LADING

PICKUP DATE

BRIEFLY DESCRIBE THE CLAIM AND HOW THE AMOUNT WAS CALCULATED

IF THE CLAIM INVOLVES DAMAGED GOODS, PLEASE CHECK ONE

PLEASE ATTACH THE APPROPRIATE DOCUMENTATION:

Damaged goods can be repaired for

Vendor's invoice showing price of lost or

damaged approximately $

goods, including final page.

Damaged goods can be repaired for

Consignee's copy of the freight bill bearing loss or

approximately $

damage notations.

__ Damaged goods are available for carrier pickup.

Itemized repair bill, if applicable.

__ Inspection Report, if available.

Damaged goods are unavailable (please explain):

CLAIMANT'S SIGNATURE & DATE

Loss And Damage Claim Form