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Loss/Damage Claim Form

[*] Denotes Required Field

Submission Date:

  September 7, 2010, 8:00 pm

Carrier Name:

 *
 

REQUEST DETAILS
Customer Name:  *  
Contact: *  
Email: *  
Phone: *  
Fax: *  
 
Pro No:  *  
BOL No: *  
Ship Date: *  
Delivery Date: *  
     
Damage:      
  - Was it refused?  Yes No  
  - Can it be repaired?   Yes No  
Concealed Damage:      
  - Can it be repaired?   Yes No  
Loss:      
Concealed Loss:      
       
  Documents Necessary to Express:  
Original Product Invoice:      
Purchase Order:      
Photos (if possible):      
       

PRODUCT

      

Description:

 Qty Unit Cost Totals  

 

 
 

REPAIR

      

Product/Parts:

 Qty Unit Cost Totals  

 

 
         
 

Labor:

 Hours Hourly Rate Totals  

 

 
 

TOTAL:

 

Please detail as much of the issue as possible:

 

Please also include any documentation you have on file that will help us resolve this claim for you!

"Attach a document by clicking the Browse button."

You may also fax additional documentation to us at: (877) 842-2270

Notes: Keep your packaging & keep any damaged freight if it cannot be repaired.

You may also fax documentation to us at: (877) 842-2270

 

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