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Shipper's Name |
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Point Shipped From |
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Name of Carrier Delivering Bill of Laden |
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Date of Bill of Laden |
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Routing of Shipment |
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Consignee's Name |
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Final Destination |
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Name of Delivering Carrier |
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Date of Delivery |
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Delivering Carrier's Freight Bill Number |
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If shipment reconsigned en route, state particulars: |
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If shipment moved from warehousing or distribution point, indicate name
of the initial shipper and point of origin, and, if known name of prior
carrier or carriers and prior billing: |
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Detailed Statement Showing How Amount Claimed Is Determined
(Number and description of articles, nature and extent of loss or damage,
invoice price of articles, amount of claim, etc. ALL DISCOUNTS and ALLOWANCES
MUST BE SHOWN)
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Style |
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Item |
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Description of
Damages |
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Cost of Item |
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Total Amount
Claimed |
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The following documents will be submitted in
the support of this claim
Please fax to
828.123.4567: |
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Original
Bill of Laden |
Shipper's
Concealed Loss or Damage Form |
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Original
Invoice |
Consignee
Concealed Loss or Damage From |
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Original
Paid Freight Bill (or other carrier documents bearing
notation of loss or damage if not shown on freight bill) |
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Carrier's
Inspection Report Form (Concealed Loss or Damage) |
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Other
Particulars Obtainable in Proof of Loss of Damage Claimed |
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(Notes: The
absence of any document called for in connection with this claim must be
explained. When impossible for claimant to provide bill of laden, or paid
freight bill, a bond of indemnity must be given to protect carrier against
duplicate claim supported by original documents.)
The Foregoing
statement of facts is hereby certified as correct. |
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Claimant's Name |
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Claimant's
Address |
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Claimant's City |
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Claimant's
State and ZIP CODE |
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Claimant's
Phone Number |
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Claimant's Fax
Number |
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