FORM OF LOSS AND DAMAGE CLAIMS
(Name of whom claim is presented) ( Name & Address of Claimant)
(Claimant's Number)*
(Date)
(Carriers Number)
This claim for $______________
(Amount of claim)
is made against the carrier above by
(Name of Claimant)
for_________________________ in connection with the following described shipment(s): Description of shipment ________________________________________________________________________ Name and address of consignor (shipper)__________________________________________________________ Shipped from__________________________________________, To__________________________________
Final Destination________________________________ Routed via_____________________________________ Bill of Lading issued by___________________________ Co.,;Date of Bill of Lading________________________ Paid Freight Bill (Pro) Number_____________________ : Original Car Number & Initial_____________________ Truck or Trailer Number__________________________ Connecting Line Reference_______________________ Name and address of consignee (Whom shipped to)_________________________________________________ List reason, description and amount of claim:
Total Amount Claimed
IN ADDITION TO THE INFORMATION GIVEN ABOVE, THE FOLLOWING DOCUMENTS ARE SUBMITTED IN SUPPORT OF THIS CLAIM.**
( ( ( ( Remarks:
) ) ) )
1. Original bill of lading, if not previously surrendered to carrier. 2. Original paid freight ("expense") bill 3. Original invoice or certified copy. 4. Other particulars obtainable in proof of loss or damage claimed.
The foregoing statement of facts is hereby certifed to as correct. Print Name: Phone No. Sign:
(Signature of claimant) * Claimant should assign to each claim a number, inserting same in the space provided in the upper right hand corner of this form. Reference should be made thereto in all correspondance pertaining to this claim.
**Claimant will please place a check (X) before such of the documents mentioned as have been attached, and explain
under "Remarks" the absence of any of the document called for in the 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(s) against duplicate claim supported by original documents.
EXEL Claim form.xls
1/25/2009