Home Claim Form 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 Afghanistan Albania Algeria American Samoa Andorra Angola Antigua and Barbuda Argentina Armenia Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Colombia Comoros Congo, Democratic Republic of the Congo, Republic of the Costa Rica Côte d'Ivoire Croatia Cuba Curaçao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Faroe Islands Fiji Finland France French Polynesia Gabon Gambia Georgia Germany Ghana Greece Greenland Grenada Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati North Korea South Korea Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mexico Micronesia Moldova Monaco Mongolia Montenegro Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Zealand Nicaragua Niger Nigeria Northern Mariana Islands Norway Oman Pakistan Palau Palestine, State of Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten Slovakia Slovenia Solomon Islands Somalia South Africa Spain Sri Lanka Sudan Sudan, South Suriname Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Yemen Zambia Zimbabwe 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 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* © 2015 J&L Transportation | All Rights Reserved