Delta Cargo Loss or Damage Claim CLAIM Air Waybill No

Delta Cargo Loss or Damage Claim 0412-90011 CLAIM 01-08 Air Waybill No. ____________________________________________________________________________________________________________________ Delta Case No. ___________________________________________________________________________________________________________________ Date of Air Waybill ____________________________________________________________________________________________________________________ Claimant's Reference No. ____________________________________________________________________________________________________________________ Goods Lost or Damaged No. Weight Description Detailed Reason for Claim Amount of Claim Total Amount of Claim Notification of loss or damage was given to at (place) Inspection was made by on (date) by [ ] Phone on (date) $ [ ] Airline Representative [ ] Letter [ ] Other ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ [ ] Airline Representative ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________ Name of Claimant __________________________________________________________________________________________________________________________ Company __________________________________________________________________________________________________________________________ Mailing Address __________________________________________________________________________________________________________________________ City ______________________________________________________________ State __________________________ Zip __________________________ Attach original or certified copy of the following supporting documents: 1. 2. 3. 4. 5. Shipment Air Waybill Purchase receipt for goods listed above Invoice for repair of goods listed above Carrier’s inspection report Statement of salvage value if applicable The foregoing statement of facts is hereby certified to as correct ____________________________________________________________________________________________________________________________________________________________________________ ________________________________________________________________ Signature of Claimant or Claimant's Representative Date ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Job Title of Claimant's Representative Send Original to: Delta Cargo Cargo Claims P. O. Box 20559 Atlanta, GA 30320-2559 Phone: 404-714-4541 Fax: 404-714-5022 Copy to: Claimant's File Reset Form INSTRUCTIONS FOR COMPLETION OF CLAIM Please include the following information when faxing or mailing in your claim. The more information you provide, the more quickly your claim will be settled. AIR WAYBILL - This is Delta’s form used to document the shipment of cargo and related information. The eight digit air waybill number is in the upper right hand corner and across the bottom of this document. AIRLINE CASE NO - This is an internal reference number that will be assigned by the carrier. CUSTOMER REF. NO. - This is an internal reference number that may be assigned by the customer. CLAIMED AMOUNT - List the damaged or missing merchandise by item and quantity. Tell us exactly what was damaged and how you determined your claim amount. For Loss or Damage: WT. OF DAMAGE/LOSS - List how many pounds/kilograms of the damaged or missing carton(s). INSPECTION REPORT - If loss or damage was noted at destination, the airline agent should have been requested to prepare this report. If an inspection was not completed, please note on the claim form. Inspections by independent surveyors may be included. INVOICE - Provide the original vendor’s invoice for the loss or damaged merchandise to indicate the value of the goods claimed. PACKING LIST - This would list the quantity and weight of the items in each box. For personal effects shipment, the value of each item should also be listed. REPAIR OR PARTS REPLACEMENT BILL - If the damaged goods are repairable, provide the estimate or receipt for repair from an established repair facility. SALVAGE VALUE - Explain what was done with the damaged shipment including the monetary amount recovered. Upon receipt of this claim and supporting information, an acknowledgment will be sent advising of any other documents that may be required. In the interim, your patience is appreciated. FREIGHT FORWARDERS AND INSURANCE COMPANIES In addition to the above, please include: HOUSE AIRBILL - Delivery record copy. SETTLEMENT DRAFT - Proof of payment to ultimate consignee. SUBROGATION RECEIPT - Statement from payee authorizing you to act on behalf of shipper or consignee.