STANDARD FORM FOR PRESENTATION OF LOSS AND DAMADGE CLAIM

MAIL TO: Fast Way Frieght
ATTN: Claims Dept

Fax to: 509-534-6975 or
Email: claims@fastwayfreight.com

CLAIMANT INFORMATION

P.O. Box 40142
Spokane, WA 99220

 

CLAIMANT NAME

 

 

AMOUNT OF CLAIM

 

ADDRESS

 

 

DATE OF CLAIM

 

CITY, ST ZIP

 

 

FREIGHT BILL #

 

PHONE NUMBER

 

 

FREIGHT BILL DATE

 

 

Claim is for:

_________

*Shortage

 

_________

**Damage

_________

**Concealed Damage

*Shortages:

The proof of loss statement on the second page must be completed for all shortage claims.

**Damages:

If the shipment delivered without noted damages, or your claim exceeds $500.00, you must

 

request an inspection from carrier within 15 days of receipt of shipment.

 

 

Shipper as shown on Bill of Lading

________________________________________________________

 

Company

 

City & State

 

Consignee as shown on Bill of Lading

________________________________________________________

 

Company

 

City & State

 

Note: Claim must be supported by the documents listed below. Insufficient documentation will delay your claim.m.

 

Documentation of Transp. Contract

 

Documentation of Value/Amount Claimed

___ Copy of Bill of Lading (If you are the shipper)

 

___ Original Invoice/Photocopy (all pages)

___ Copy of Freight Bill (If you are the consignee)

___ Original Repair Invoice/Photocopy **

___ Standard Damage Claim Form

 

** Please itemize all repair costs. Include a copy

 

of the invoice for repairs.

 

 

DETAILED STATEMENT SHOWING HOW AMOUNT CLAIMED WAS DETERMINED

 

(Number/description of articles, nature of loss or damage, invoice price or articles, amount)nt of claim etc)

AMOUNT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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.

Claimant's Signature

 

Name and Address exactly as they should appear on Claimant Check:

 

 

 

 

 

Printed Name

 

 

 

 

 

 

Review information on page two of this document before submitting.

 

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.

 

SALVAGE RETENTION

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.

 

DOCUMENTS REQUIRED IN SUPPORT OF CLAIMS


       (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.

 

Notice

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.

Remarks:

 

 

 

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