Shipper Name*
Ship From*
Phone Number*
Consignee Name*
Date of Damage/Loss*
Detailed Statement indicating how damage occurred*
Amount Claimed (USD)*
PO# or SO#*
Carrier Name/PRO# (if known)
Date Request Intiated*
Claim Requested By*
Other supporting documents
Any other supporting paperwork that may have gone with the shipment (Please specify)*
