|
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 |