Claim Form

*Required Fields Load Date: *

Delivery Date: *

Origin Address: *

Shipment Type:*

Valuation Type:*

Name: *

Home Phone: *

Work Phone:

Fax #:

Email Address:*

Street:*

City:*

State:*

Zip:*

Statement of Claim

Click Here for Instructions on completing this form

All sections must be completed - No repairs or discarding should begin prior to carrier inspection

Inventory Item #	Article - Describe in Detail	Nature of Claim If Damaged, Describe Extent	Approx. Weight	Year Purchased	Cost	Amount Claimed

Comments: