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Preliminary Notification of Loss/Damage
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NOTE: COMPLETION OF THIS FORM DOES NOT CONSTITUTE A FORMAL CLAIM
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Please fill out the information below as completely as possible.
Fields in Blue are required.
By filling out this information inaccurately, your claim may be denied.
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Upon submission, a formal claim will be sent to the billable party within 3 business days via the contact method selected below.
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Pilot Shipment #:
(Required)
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Claimant Information
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Company Name:
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Contact Name:
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Contact Phone:
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Contact Email:
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Contact Fax:
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Contact via:
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Claimant Address
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Address:
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City:
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State/Province:
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Postal Code:
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Country:
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Shipment Information
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Pickup Date:
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mm/dd/yyyy
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Delivery Date:
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mm/dd/yyyy
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Claimant Role:
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Type Of Claim:
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Total Pieces Shipped:
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Total Weight Shipped:
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# of Pieces Lost/Damaged:
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Extent of Damage:
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Value Type:
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Amount ($):
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Commodity/ Description of Goods:
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Comments:
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