Standard Form For Presentation Of Loss And Damage Claims

Standard Form for Presentation of Loss and Damage Claims

(Claimant's Number)*

(Company name of Claimant)

(Address of claimant)

(Name of Carrier)

(Date)

(PRO Number)

(Address)

This claim for

$___________ is made against the carrier named above by

(Name of Claimant)

(Amount of claim)

for

in connection with the following described shipment(s):

(Loss or damage)

Description of shipment

Name and address of consignor (shipper)

Shipped from

,to

(City, Town or Station)

(City, Town, or Station)

Final Destination

Routed via

(City, Town or Station)

Bill of lading issued by:

Date of Bill of Lading:

Paid Freight Bill (Pro) Number:

Name and address of Consignee (Whom shipped to)

If shipment reconsigned enroute, 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

IN ADDITION TO THE INFORMATION GIVEN ABOVE, THE FOLLOWING DOCUMENTS ARE SUBMITTED IN SUPPORT OF THIS CLAIM**

(

)

1. Original bill of lading, if not previously surrendered to carrier.

(

)

2. Original paid freight ("expense") bill.

(

)

3. Original invoice or certified copy showing claimants cost.

(

)

4. Other particulars obtainable in proof of loss or damage claimed.

Remarks:

The foregoing statements of facts is hereby certified to as correct.

Printed name of claimant (print clearly)

(Claimants contact phone number)

(Signature of claimant)

*Claimant should assign to each claim a number, inserting same in the space provided at the upper right hand corner of this form. Reference should be made thereto in all correspondence

pertaining to this claim.

**Claimant will please place check ( X ) before such of the documents mentioned as have been attached, and explain under "Remarks" the absence of any of the documents called for

in connection with this claim. When for any reason it is impossible for claimant to produce original bill of lading, or paid freight bill, claimant should indemnify carrier or carriers against duplicate claim

supported by original documents.