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CARGO LOSS AND DAMAGE CLAIM


Review the information page before completing this form.

These items must be completed or your claim will be returned
Claim Amount
PRO No. and Pickup Date (If unknown,attach a copy of the bill of loading )
PRO No. P/U Date PickDate
Date PickDate
Preparer Name
Your Reference#(optional)
Fax To: Mail To:
Claimant's correspondence address(Mailing Address)
Claimant's name(Please print)
Address
City
State
Zip
Phone#
Fax#
Make check payable to(REMIT TO)(complete only if different from correspondence)
Claimant's name(Please print)
Address
City
State
Zip
Phone#
Fax#
Shipper
Shipper City
Shipper State
Shipper Zip
Consignee
Consignee City
Consignee State
Consignee Zip
(Specify if other) 
Briefly describe what the claim represents and how the claim amount was calculated
   
If the claim involves damaged goods please check one or more of the following
Please attach copies of;






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