Loss and Damage Claim Form
Instructions
Claimant Reference #
(Optional)
Carrier Pro #
(Required)
Shipper
Name
Address
City
State
Zip
Claimant
Name
Address
City
State
Zip
Consignee
Name
Address
City
State
Zip
Remit To (IF DIFFERENT THAN CLAIMANT)
Name
Address
City
State
Zip
Reason for filing:
Shortage
Visible Damage
Concealed Damage
Other
DETAILED STATEMENT SHOWING HOW CLAIM AMOUNT IS DETERMINED
Include number and description of articles, nature and extent of loss or damage, invoice cost of articles, amount of claim, weight, etc.
Description
Invoice Cost
$
$
$
REQUIRED:
Total weight of lost / damaged product:
lbs
NMFC Item Numbers of commodity lost or damaged:
Total Amount Claimed:
$
Total Amount Claimed:
$
REQUIRED: Total weight of lost / damaged product:
lbs
NMFC Item Numbers of commodity lost or damaged:
COMMENTS
(Optional):
THE FOLLOWING DOCUMENTS ARE SUBMITTED IN SUPPORT OF THIS CLAIM:
Attach File
Original invoice or certified copy
(REQUIRED)
Attach File
Delivery Receipt
Attach File
Breakdown or repair charges
Attach File
Inspection or waiver of inspection
Attach File
Pictures of claimed product
(If uploading multiple pictures they must all be selected at once)
Attach File
Other particulars obtainable in proof of loss or damage claimed
THE FOREGOING STATEMENT OF FACTS IS HEREBY CERTIFIED AS CORRECT:
Contact Name
Company Name
Phone
Email
Date:
Signature:
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Claim #
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has been assigned.
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Claim Summary
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