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T h i s C l a i m i s f o r : F O R M C H E C K B O X D a m a g e F O R M C H E C K B O X S h o r t a g e
C l a i m a n t : F O R M T E X T C o n t a c t N a m e : F O R M T E X T
A d d r e s s : F O R M T E X T
C i t y : F O R M T E X T S t a t e : F O R M T E X T Z I P : F O R M T E X T
P h o n e # : ( F O R M T E X T ) F O R M T E X T
S h i p p e r : F O R M T E X T
A d d r e s s : F O R M T E X T
C i t y : F O R M T E X T S t a t e : F O R M T E X T Z I P : F O R M T E X T
P h o n e # : ( F O R M T E X T ) F O R M T E X T
C o n s i g n e e : F O R M T E X T
A d d r e s s : F O R M T E X T
C i t y : F O R M T E X T S t a t e : F O R M T E X T Z I P : F O R M T E X T
P h o n e # : ( F O R M T E X T ) F O R M T E X T
P r o # : F O R M T E X T B i l l o f L a d i n g D a t e : F O R M T E X T W e i g h t o f S h i p m e n t : F O R M T E X T l b s .
C h e c k O n e : F O R M C H E C K B O X F u l l V a l u e F O R M C H E C K B O X R e p l a c e m e n t F O R M C H E C K B O X R e p a i r
# o f P C S . D e s c r i p t i o n o f s h o r t o r d a m a g e d a r t i c l e s , i n c l u d i n g m o d e l # , e t c .
F O R M T E X T F O R M T E X T $ F O R M T E X T
F O R M T E X T F O R M T E X T $ F O R M T E X T
F O R M T E X T F O R M T E X T $ F O R M T E X T
F O R M T E X T F O R M T E X T $ F O R M T E X T
F O R M T E X T F O R M T E X T $ F O R M T E X T
F O R M T E X T F O R M T E X T $ F O R M T E X T
F O R M T E X T F O R M T E X T $ F O R M T E X T
T o t a l A m o u n t C l a i m e d $ F O R M T E X T
I M P O R T A N T N O T E T O O U R C U S T O M E R S : T H E F O L L O W ING DOCUMENTS MUST BE INCLUDED TO PROCESS YOUR CLAIM. ALSO, FREIGHT CHARGES MUST BE PAID IN FULL BEFORE THIS CLAIM CAN BE PROCESSED.
1. Signed and dated claim form.
2. Legible copy of the freight bill, bill of lading, and delivery receipt
3. If this was an intermodal shipment copies of all Bills of Lading and delivery receipts required for all transportation segments.
4. Original vendors invoice (proof of purchase cost) showing all discounts.
5. Invoice for repair or repackaging, showing breakdown by labor by hour and rate of pay, if applicable.
6. Invoice for materials purchased to complete repair or repackaging, if applicable.
7. Pictures of damage and/or packaging.
8. Salvage value, if applicable.
The claimant certifies the foregoing to be correct, and agrees to indemnify FedEx Custom Critical and the transporting carrier against loss in the event the original Bill of Lading and/or original freight bill are not submitted.
Signature of Claimant: FORMTEXT
P r i n t N a m e : F O R M T E X T D a t e : F O R M T E X T
C L M S _ 0 0 1 _ 1 1 5
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