U.S. Transport Services
Standard Form for Presentation of Loss and Damage Claim

  Date:
 

,

Name of Carrier: Claimants No.
Mailing Address: Carrier's No.
City: State: Zip:  
 

This claim for $ is made against your company for

with the following shipment:

Shipper's Name: Consignee's Name:
Point Shipped From: Final Destination:
Name of Carrier Issuing Bill of Lading: Name of Delivering Carrier:
Date of Bill of Lading: Date of Delivery:
, ,
Routing of Shipment: Delivering Carrier's Freight Bill No.

If shipment re consigned en route, 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. All discounts and all allowances must be shown.)

Description (Include NMFC Number) Amount
Total Amount Claimed:

The Following documents are submitted in support of this claim:

Original Bill of Lading


Original paid freight bill or other document bearing notation of loss or damage
if not shown on freight bill


Carrier's Inspection Report


Original Invoice or certified copy


Shipper's or consignee's concealed loss or damage form

 

In the absence of the Original Freight Bill and/or Original Bill of Lading, we agree to hold the above named carrier to whom this claim is presented and any other participating carrier harmless and indemnified against any and all lawful claim which may be made against it of them arising out of the same shipment and will pay to the said carrier and any of them may suffer or pay by reason of payment of our claim, herein described, without the surrender of the Original Freight Bill or Bill of Lading, as such was not provided and/or cannot be located.

The foregoing statement of facts is hereby certified as correct

Date:

,

Name:

Email:

Company:

Address:

City: State: Zip:  
 

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