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STANDARD FORM FOR PRESENTATION OF LOSS AND DAMADGE CLAIM |
MAIL TO: Fast Way Frieght |
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Fax to: 509-534-6975 or |
CLAIMANT INFORMATION |
P.O. Box 40142 |
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CLAIMANT NAME |
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AMOUNT OF CLAIM |
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ADDRESS |
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DATE OF CLAIM |
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CITY, ST ZIP |
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FREIGHT BILL # |
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PHONE NUMBER |
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FREIGHT BILL DATE |
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Claim is for: |
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*Shortage |
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**Damage |
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**Concealed Damage |
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*Shortages: |
The proof of loss statement on the second page must be completed for all shortage claims. |
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**Damages: |
If the shipment delivered without noted damages, or your claim exceeds $500.00, you must |
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request an inspection from carrier within 15 days of receipt of shipment. |
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Shipper as shown on Bill of Lading |
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Company |
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City & State |
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Consignee as shown on Bill of Lading |
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Company |
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City & State |
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Note: Claim must be supported by the documents listed below. Insufficient documentation will delay your claim. |
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Documentation of Transp. Contract |
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Documentation of Value/Amount Claimed |
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___ Copy of Bill of Lading (If you are the shipper) |
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___ Original Invoice/Photocopy (all pages) |
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___ Copy of Freight Bill (If you are the consignee) |
___ Original Repair Invoice/Photocopy ** |
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___ Standard Damage Claim Form |
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** Please itemize all repair costs. Include a copy |
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of the invoice for repairs. |
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DETAILED STATEMENT SHOWING HOW AMOUNT CLAIMED WAS DETERMINED |
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(Number/description of articles, nature of loss or damage, invoice price or articles, amount) |
AMOUNT |
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The foregoing statement of facts is hereby certified to be correct, and all copies of invoices attached are also certified to be the exact copies of the original invoice. It is also agreed that Fast Way Freigth and its connections are indemnified against any loss that might arise from payment of this claim without the original paid freight bill and/or original Bill of Lading. |
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Claimant's Signature |
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Name and Address exactly as they should appear on Claimant Check: |
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Printed Name |
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Review information on page two of this document before submitting. |
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PROOF OF LOSS STATEMENT
This is to certify that the shortage described in this claim has not been received from any source to date, and in the event said shortages are received, we hereby agree to notify Fast Way Freight System, Inc. immediately, advising the name of the carrier delivering and their billing reference. We further agree to return the merchandise to the above named carrier if requested to do so, or reimburse said carrier the amount paid in settlement of the claim covered by this shortage. We fully understand that the interstate commerce provides fines for anyone guilty of filing a false or fraudulent claim on an interstate shipment and with that knowledge hereby certify that the above shortage still exists and recognize our obligation to inform the above carrier in the event the merchandise now short is subsequently delivered to us by any means.
| COMPANY NAME (Please print) | __________________________________________________ |
| CLAIMANT SIGNATURE | __________________________________________________ |
| TITLE | __________________________________________________ |
| DATE | __________________________________________________ |
It is the duty of the consignee to retain the damaged merchandise and shipping container until the carrier desires to take possession of merchandise as salvage. This only applies when the carrier and consignee agree that the carrier will handle the disposition of the salvage, and does not in any manner affect the legal duty of the shipper and consignee, when there is substantial value in the salvage, to accept and handle materials in such a manner as to mitigate the carriers loss as much as possible.
(a) A
written demand for payment, asserting carrier liability for alleged loss,
damage, injury or delay, and containing facts sufficient to identify the
shipment or shipments involved will constitute a claim, regardless of form, and
will be required.
(b) When claimant does not appear from the
supporting documents to be an interested party, carrier will require any
necessary written assignment or other proof to determine the claimant is the
proper party to receive any claim payment.
(c) Claim must be supported by either the
original invoice; a photographic copy of the original invoice; an exact copy
thereof, or an extract therefrom, certified by the claimant or his authorized
representative to be true and correct with respect to the property involved in
the claim and reflecting all trade or other discounts, allowances, or
deductions of any nature. When the original invoice is not submitted, such
document must be made available for inspection by carrier representative upon
request.
(d) When determined by the carrier to be a
necessary part of the investigation, the following will be required:
1. The
original freight bill and bill of lading or other contract of carriage. When
claimant cannot furnish these documents, carrier may require suitable indemnity
from the claimant.
2. When the
property involved in the claim has not been invoiced to the consignee or where
invoice does not show price or value, or where the property has not been sold
but transferred at bookkeeping values only, or where property has been shipped
on consignment or approval, documentation to establish destination value in the
quantity shipped and certification of the correctness thereof.
3. In order
to establish the full recoverable loss caused by the carriers, the original
account of sale, showing the date of sale and the amounts realized on the
damaged and undamaged portions, respectively, showing grade, brands, quality,
variety, size and condition, together with any deductions, allowances, and
commissions, or a copy thereof certified correct over the signature of the
claimant or an authorized representative thereof.
4. When
shipment has received prior transportation and is reshipped from a distribution
or warehousing point but has been opened and examined and contents verified as
being in undamaged condition, certification thereof must be made by a person
having actual knowledge of such inspection and a statement to that effect
incorporated in such certification.
5. When an
asserted claim for loss of an entire package or on an entire shipment cannot be
otherwise authenticated upon investigation, the carrier will obtain from the
consignee of the shipment involved, a certified statement in writing that the
property for which the claim is filed has not been received from any source.
Carriers and their agents are bound by the provisions of law, and any deviation therefrom by the payment and claims before the facts and measure of legal liability are established will render them as well as the claimant, liable to fines and penalties by law.
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| PAGE 2 |