Standard Form For Presentation Of Loss And Damage Claims printable pdf download

Standard Form for Presentation of Loss and Damage Claims

_____________________________________

______________________________________

_____________________

(Name of person to whom claim is presented)

(Address of Claimant)

(Claimant’s Number)

_____________________________________

_______________________________

_____________________

(Name of carrier)

(Date)

(Carrier’s Number)

_____________________________________

(Address)

This claim for $ ______________________ is made against the carrier named above by ________________________________________________

(Amount of claim)

(Name of Claimant)

for __________________________ in connection with the following described shipments:

(Loss or damage)

Description of shipment ____________________________________________________________________________________________________

Name and address of consignor (shipper) ______________________________________________________________________________________

Shipped from _______________________________________________; To ________________________________________________________

(City, town or station, state/province and post code)

Final Destination ____________________________________________; Routed via __________________________________________________

(City, town or station, state/province and post code)

Bill of Lading issued by _______________________________________; Date of Bill of Lading _________________________________________

Paid Freight Bill (Pro) Number _________________________________; Value declared on Bill of Lading $ ______________________________

Name and Address of Consignee (Whom shipped to) _____________________________________________________________________________

If shipment reconsigned en route, state particulars: _______________________________________________________________________________

DETAILED STATEMENT SHOWING HOW AMOUNT CLAIMED IS DETERMINED

(Number and description of articles, nature and extent of loss or damage, invoice price of articles, amount of claim, etc.)

_______________________________________________________________________________________________________________________________________

Total Amount Claimed:

Additional Remarks: _______________________________________________________________________________________________________

________________________________________________________________________________________________________________________

The forgoing statement of facts is hereby certified to as correct. ___________________________________________

______________________

(Signature of claimant)

(Date)

(rev. 0904)

____________________________________________________________________________

(Printed name and title of claimant)

Standard Form For Presentation Of Loss And Damage Claims