This claim for $ is made against your company for DamageLoss in connection with the following shipment:


If shipment reconsigned en route, state particulars:


If shipment moved from warehousing or distribution point, indicate name of initial shipper and point of origin, and, if known, name of prior carrier or carriers and prior billing references:

Detailed Statement Showing How Amount Claimed is Determined

(Number and description of articles, nature and extent loss or damage, invoice price of articles, ALL DISCOUNT and ALLOWANCES MUST BE SHOWN.)

NMFC Item No. of commodity lost or damaged

Total amount claimed

The following documents are submitted in support of this claim:

Original Bill of LadingOriginal invoice or certified copyOriginal paid freight bill or other carrier document bearing notation of loss or damage if not shown on freight billCarrier's inspection report from (concealed loss or damage)Shipper's concealed loss or damage formConsignee concealed loss or damage formOther particulars obtainable in proof of loss or damage claimed

(Note: The absence of any document called for in connection with this claim must be explained. When impossible for claimant to produce original bill of lading, or paid freight bill, a bond of indemnity must be given to protect carrier against duplicate claim supported by original documents.)