Claim Form

Standard Form For Presentation Of Loss And Damage Claims Under Uniform Household Goods Bill Of Lading

IMPORTANT INFORMATION BEFORE FILING CLAIM

TO CLAIMANTS:
Claimants are requested to make use of this form for filing claims.

Claims may be filed with the carrier's agent either at the point of origin or destination of shipment, or direct with the Claim Department of the Carrier, and will be considered properly presented only when the information and documents called for in the form below have, as far as possible, been supplied. A duplicate copy thereof should be preserved by the claimant. It is the desire of carrier to settle promptly all valid claims, and the frank and hearty co-operation of the claimant is therefore solicited.

IMPORTANT INFORMATION TO BE READ CAREFULLY BEFORE FILING CLAIM
Before presenting a claim on account of loss or damages, the following important information respecting claims should be given careful consideration:

1. The terms under which property is accepted and transported by the carrier are stated on the bill of lading issued by the carrier, also in tariffs and classifications Issued by the carrier and filed in compliance with Federal and State laws. Persons intending to file claims, should before doing so, examine the terms and conditions under which property was accepted and transported.

2. Carriers and their agents are bound by the provisions of law, and any deviation therefrom by the payment of claims before the facts and measure of legal liability are established will render them, as well as the claimant, liable to the fines and penalties by law.

3. In order that the carrier may have an opportunity to inspect goods and thereby properly verify claims any loss or damage discovered while goods are being packed, loaded, unloaded, or unpacked, should be immediately brought to the attention of agents of carrier who are performing service of packing, loading, unloading or packing, and proper notations should be made on Bill of Lading, freight bills or other documents pertaining to shipment, and signed for, by the carrier's agent performing this service immediately.

Loss or damage discovered after delivery should be reported to the carrier as for as possible immediately or within forty-eight hours after receipt of goods by the consignee. Consignee should leave article as near as possible in position placed by carrier, and should preserve for the carrier all portions of containers, packages or wrappers of shipments damaged bearing names, addresses, numbers, marks, label , etc., and consignee should allow carrier reasonable time to inspect alleged loss or damage in original package, container or wrapper, and as near as possible in position where article was placed by carrier.

4. Under the provisions of the Motor Carrier Act of 1935 it is unlawful for a carrier to charge or demand or collect or receive any greater or less different compensation for the transportation of property than the rates and charges named in tariffs lawfully on file, nor to refund or remit in any manner or by any device any portion of the rates and charges so specified. The refund or remission of any portion of the rate and charges so specified through the payment of fraudulent, fictitious or excessive claims for loss or damage to property transported is as much a violation of the law as is direct concession or departure from the published rates and charges.

SUBDIVISION (c) of section 222 "MOTOR CARRIER ACT OF 1935" READS:

* * (c) Any person whether carrier, shipper, consignee, or broker or any officer, employee, agent, or representative thereof, who shall knowingly offer, grant, or give, or solicit, accept, or receive any rebate, concession, or discrimination in violation of any provision of this port, or who by means of any false statement or representation, or by the use of any false or fictitious bill, bill of lading, receipt, voucher, roll, account, claim, certificate, affidavit, deposition, lease, or bill of sale, or by any other means or device, shall knowingly and willfully assist, suffer or permit any person or persons, natural or artificial, to obtain transportation of passengers or property subject to this port for less than the applic-able rate, fare, or charge, or who shall knowingly and willfully by any such means or otherwise fraudulently seek to evade or defeat regulation as in this part provided for motor carrier or broker, shall be deemed guilty of a misdemeanor and upon conviction thereof be fined not more than $500 for the first offense and not more than $2,000 for subsequent offence."

5. ANY CLAIM FOR LOSS, DAMAGE, OR OVERCHARGE MUST BE SWORN TO BEFORE A NOTARY PUBLIC OR OTHER OFFICER VESTED WITH AUTHORITY TO ADMINISTER AN OATH. This carrier positively will not recognize a claim unless the claim form is notarized and sworn to.
To
Name of Carrier on Bill of Lading*
Date*
Date Format: MM slash DD slash YYYY
Address*
Street Address City State ZIP Code
Bill of Lading or Shipment No.*
Claimant No.*
Carrier D/L No.*

Claim is made against your company for

*
- Damage
- Loss

in connection with the following shipment.*

From

Shipper or Consignor on Bill of Lading*
Address*
Street Address City State ZIP Code
Warehouse Name Loaded From*

To

Consignee*
Address*
Street Address City State ZIP Code
Warehouse Name if Delivered to Warehouse

Total value of goods shipped on this bill of lading*
Replacement Cost*
Total transit insurance secured by carrier for you*
Did you pay a premium?*
- Yes
- No

Released value shown on bill of lading

Number*

Cts. per pound per article *

Detailed Statement showing how amount claimed is determined

List Number, Description of item, Nature and extent of loss or damage*
Date Acquired*
MM
DD
YYYY
Original Cost*
Weight*
Amount Claimed*
*This button is currently under construction* It will add a new row of inputs from "List Number" to "Amount claimed".

Your claim cannot be settled unless freight charges are paid and paid bill attached to this claim, or Indemnity Bond made against duplicate claim. Your can be handled quicker if you attach a repair estimate from a reliable repairman.

Reference should be made to the "Claimant No." in all correspondence pertaining to this claim claimant will please explain under "Remarks" the absence of any of the documents called for in connection with this claim. When for any reason it is impossible for claimant to produce original bill of lading or paid freight bill, claimant should indemnify carrier or carriers against duplicate claim, supported by original document.

NOTE: IF CLAIM IS TO BE SETTLED WITH ANOTHER PARTY, SO AUTHROIZE UNDER "REMARKS"
Paid Bill or Indemnity Bond Documentation
Accepted file types: pdf, doc, docx, odt.
Repair Estimate Documentation
Accepted file types: pdf, doc, docx, odt.
Remarks:

The undersigned, signer of the foregoing statement, hereby make a solemn oath to the truth of statements containing herein, and exhibits attached hereto and that no material fact is withheld that should be included in this report. For the purpose of obtaining money on the above claim, I hereby demand

which is to be considered as a full release and discharge from any and all claims and demands accruing prior to this date, and particularly from any and all claims and demands rising out of the transportation described in the foregoing statement. *

Signature*
Consent*
I have read the Important Information
STATE OF ______________________

COUNTY OF _____________________

Sworn to before me this _ _ _ _ _ _ _ day of _ _ _ _ _ _

________________________________________________

(Notary Public)

My Commission expires ______________________________________

_______________________________________________

(Signature of Claimant)

_______________________________________________

Present Address

Standard Form For Presentation Of Loss And Damage Claims Under Uniform Household Goods Bill Of Lading

IMPORTANT INFORMATION BEFORE FILING CLAIM

TO CLAIMANTS:

IMPORTANT INFORMATION TO BE READ CAREFULLY BEFORE FILING CLAIM

To

From

To

Detailed Statement showing how amount claimed is determined

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