CLAIM FOR LOSS OR DAMAGE
                                                      
Claimant
                                                      
Date
                                                      
Claimant Mailing Address
                                                      
Claimant File# (Claimant Assigns)
                                                      
City, State, Zip
                                                      
Amount of Claim
                                                      
Phone Number
                                                      
Freight Bill Number
                                                      
Claiment Contact Name
                                                      
Shipment Date (Pick Up Date)
                                                      
Shipper
                                                      
Bill of Lading Number (If Known)
                                                      
Consignee