J & L Claim Form - JL Transportation

Claimant's Name

First Last

Date*

MM

DD

YYYY

Claimant's Claim #*

Claimant's Freight Bill #*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

This Claim is for $ (Dollar Amount) is made against your company*

Enter Dollar Amount

This Claim is for?*

Damage
Loss

Select all that apply

Was the Damage Concealed?*

No
Yes

Shippers Information*

Shippers Name	Address	City, State, Zip

Consignee's Information*

Consignee Name	Address	City, State, Zip

Do you have paperwork to upload?*

Yes
No

Upload All Information*

Drop files here or

DETAILED STATEMENT SHOWING HOW CLAIM AMOUNT WAS DETERMINED*

(Number and description of articles, nature and extent of loss or damage, original price of articles, amount of claim, etc. ALL DISCOUNT and ALLOWANCES MUST ME SHOWN.)

Repair or Discounted Amount $

Enter $ Value

Total Amount Claimed $*

Enter $ Value

The following documents are submitted in support of this claim:*

None
Original Bill of Lading
Original Invoice or certified copy
Shippers Concealed Loss
Original paid freight bill or other carrier documents bearing notation of loss or damage if not shown on freight bill
Carrier's Inspection Report form (Concealed loss or damage)
Consignee Concealed Loss or Damage Form

List any other particulars upload for review

(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 duplicate claim supported by original documents.)

Indemnity Agreement

In the absence of the ORIGINAL freight Bill and/or Original bill of lading, we agree to hold the above named carrier to whom this claim is presented and any other participating carrier, harmless and Indemnified against any and all lawful claims which may be made against it or them arising out of the same shipment and will pay to the said carrier and any participating carriers(s), all 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 was not provided and/or cannot be located.

Claimant's Name*

Todays Date*

MM

DD

YYYY

Your Signature*