Claims Form

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Name *

Email *

Phone *

Fax

Claimant Information

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Company Name *

Address 1 *

Address 2

City *

ST/Prov *

Zip *

ST/Prov

Zip

Claim Information

Claim Amount (format 0000.00 - no commas) *

Your Claim Number (for your reference - if applicable)

Type of Claim *

Shortage

Damage

Other (If other please provide details below)

Other Claim Details

Shipper *

Consignee *

Origin *

Destination *

Pro No. *

Date of Delivery *

Briefly describe what the claim represents and show how the amount of the claim was calculated

If the claim involves damaged goods, please check one or more of the following:

Damaged goods can be repaired for approximately

Repair amount

Damaged goods can be used 'as is' for an allowance of

Allowance amount

Damaged goods are available for carrier pickup

Damaged goods are unavailable (please explain below)

To avoid delay in processing your claim, please attach appropriate documentation, as follows:

Vendor’s invoice showing price of lost or damaged goods (be sure to include final page)

Consignee’s copy of freight bill bearing loss or damage notations

Itemized repair bill (if applicable)

Inspection report (if available)

Attach files here:
Attach files here: If your attachment file size is in excess of the maximum upload size, please email the attachments to our Claims Department & be sure to include YOUR claim number, the Pro # and the claimant name.

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