Standard Form for Presentation of Loss and Damage Claims Claimant * Email Address * Address * City * State* Select a State/Province Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware D.C. Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Alberta British Columbia Manitoba New Brunswick New Foundland Nova Scotia Northwest Territory Ontario Price Edward Island Quebec Saskatchewan Yukon Zip * Contact Name * Phone * Our pro number. *(It will need to be paid before we open your claim.) No such Pro Number exists. Your claim cannot be submitted without a correct Pro Number. Your reference or claim Date of shipment * Total claim amount * Currency * USD CND Total Weight of Damaged Item * This claim is due to:* Noted damage Concealed damage Shortage Theft Was this item refused at delivery?* Yes No If no, please advise the location of the damaged unit:* Are the damaged goods available for carrier pickup?* Yes No If no, please explain why the goods are unavailable:* What type of damage?* Cosmetic Functionality Can the item be repaired?* Yes No If yes, please provide the repair quote and/or invoice.* If no, please advise as to why no repair can be made:* Is there any salvage opportunity for the item if no repair can be made?* Yes No Shipper Name * Address * City * State* Select a State/Province Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware D.C. Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Alberta British Columbia Manitoba New Brunswick New Foundland Nova Scotia Northwest Territory Ontario Price Edward Island Quebec Saskatchewan Yukon Zip * Consignee Name * Address * City * State* Select a State/Province Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware D.C. Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Alberta British Columbia Manitoba New Brunswick New Foundland Nova Scotia Northwest Territory Ontario Price Edward Island Quebec Saskatchewan Yukon Zip * DETAILED STATEMENT SHOWING HOW CLAIM AMOUNT IS DETERMINED. (Number and description of articles, nature and extent of loss or damage, invoice price of articles, amount of claim, etc)SHOW ALL DISCOUNTS AND ALLOWANCES Detail of Damage and/or Item Numbers* Amount* Upload Documents (10 MB max for all the documents combined.) Original invoice * Add More Photos supporting claim Add More Other documents supporting claim Add More WHEN FOR ANY REASON, THE ORIGINAL PAID FREIGHT BILL OR BILL OF LADING IS NOT PROVIDED, CLAIMANT MUST INDEMNIFY CARRIER OR CARRIERS AGAINST DUPLICATE CLAIMS SUPPORTED BY ORIGINAL DOCUMENTS INDEMNITY AGREEMENT When the original bill of lading and/or freight bill is not submitted, or is not available for submission, but copies of the original are submitted in support of the claim described above, the claimant agrees to indemnify and hold harmless the carrier receiving this claim, named above, and any participating carriers, and will pay to the carrier or any participating carrier all losses, costs, damages, counsel fees or any other expenses it (the carrier) may incur resulting from all lawful subsequent duplicate claims arising out of the same shipment which may be filed and supported by the original documents. Foregoing statement of fact is hereby certified as correct. Name * DATE * Signature Enter the contents of image*
