Claimant: Company Name: Address: City/State/Zip: Phone Number: Email: Shipper: Address: City/State/Zip: Consignee: Address: City/State/Zip: Claimant's Reference Number(s): Claim Information: Noted Damage Concealed Damage Shortage Other (explain) Damaged goods can be used for an allowance of $ Damaged goods can be repaired for $ Damaged goods are located at Damaged goods are not available (explain) Pieces Weight Used Description Amount Claimed Total: $0.00
