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Presentation of Loss and Damage Claim Form
Customer Ref# Date:
DFI Pro#
Order # Fed TaxID:  

Claim Details

I am claiming the amount of $     due to  Damage   Loss in connection with the following shipment:

Shipper's Name

Consignee's Name:

Point Shipped From (Company Name)

Final Destination (Company Name)






Zip/Postal Code


Zip/Postal Code

Date of Delivery

Consignee Phone Number

Name of Carrier

Carrier's Freight Bill #(if known)
If shipment reconsigned en route, state particulars

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 all allowances must be shown

DESCRIPTION (Include NMFC Number) Amount $

The following documents are submitted in support of this claim (please check all that apply):

Original Bill of Lading
Original paid freight bill or other document bearing notation of loss/damage if not shown on freight bill
Carrier's Inspection Report
Original Invoice or certified copy
Shipper's or consignee's concealed loss or damage form

Attach other documents which might help resolve this claim

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

Attach File(s) Uploaded File(s)


In the absence of the Original Freight Bill and/or Original Bill of Lading, we agree to hold the above named carrier (and its agent, Ameri-Co Carriers/Logistics, Inc.) to whom this claim is presented and any other participating carrier harmless and indemnified against any and all lawful claim which may be made against it or them arising out of the same shipment and will pay to the said carrier and any participating carrier(s) and their agent, Ameri-Co Carriers/Logistics, Inc., any perceived or actual losses, damages, costs, counsel fees or any other expenses which they or any of them may suffer or pay by reason of payment of our claim, herein described, without the surrender of the Original Freight Bill or Bill of Lading, as such was not provided and/or cannot be located.

The foregoing statement of facts is hereby certiffied as correct and signed by either an officer of the company or a legally responsible party.

Name: Address:
Company: City:
Title: State:
Email:   Zip Code:
Please re-enter your TAX ID# as your signature.  
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