Claims Form

Claimant's Name

Claimant’s Address

Claimant’s Phone Number

Date

This claim for $

is made against your company for

Loss

Damage

In connection with the following described shipment:

Shipper’s Name

Consignee’s Name

Pick-up Point

Drop-Off Point

Name of Carrier Issuing Bill of Lading

(Name of Carrier Issuing Bill of Lading)

Date of Bill of Lading

Date of Delivery

Routing of Shipment)

Delivering Carrier’s Freight Bill No.

If shipment reconsigned enroute, state particulars

State further particulars, if necessary

DETAILED STATEMENT SHOWING HOW AMOUNT CLAIMED IS DETERMINED

Number & description of articles, nature & extent of loss or damage, invoice prices of articles, amount of claim etc.)

ALL DISCOUNTS AND ALLOWANCES MUST BE SHOWN

NMFC Item No. of commodity lost or damaged

Total Amount Claimed

In addition to the above, the following documents are submitted in support of this claim:

Original Bill of Lading

Original Paid Freight (“Expense”) Bill

Original Invoice or Certified Copy showing Claimant’s Loss

Other particulars obtainable in proof of loss or damage claimed

(Note: The absence of any document called for in connection with this claim must be explained. When impossible for claimants to produce original documents of lading or unpaid freight bill, a bond of indemnity must be given to the carrier against duplicate claim supported by original documents).

INDEMNITY AGREEMENT

The foregoing statement of facts is hereby certified as correct.

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 claims which may be made against it or arising out of the same shipment and will pay to the said carrier and any participating carrier(s).

Claimant’s Phone No.

Date

Company Name

Claimant’s Address

Claimant’s Email

Signature

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Claims Form – Sample Page

Claims Form

Claims Form

In connection with the following described shipment:

DETAILED STATEMENT SHOWING HOW AMOUNT CLAIMED IS DETERMINED

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