Claim Form

Loss/Damage Claim Form

Quantity Unit Description Detailed reason for claim Amount of claim
Total Amount of Claim

Notification of loss or damage was given to


Inspection was made by:

Attach original or certified copy of the following supporting documents (please note that if you have multiple documents to send for any of the following 7 items, you can only upload ONE file for each of the 7 categories. If you have multiple docs for any one of them, you must scan them as a single document.

1. Copy of Housebill

2. Copy of Delivery Receipt or receipt of refusal

3. Copy of original Receipt of purchase

4. Copy of Receipt or replacement

5. Copy of your clients claim against you

6. Photo of inner & outer Packaging & Damaged items
(for damage claims)

7. Proof of payment by you to your claimant

The foregoing statement of facts is hereby certified to as correct: