SEKO Shipping No.
 Date Shipped
 Other Carrier Bill No.
 Claimant Ref No.
 Ship From:
 City / State
 Ship To:
 City / State
 Type of Claim
   Were the articles:
 Detailed Statement Showing how amount claimed is determined: Include number and description of articles, if only a portion of the shipment is lost or damaged, indicate how many pieces in total shipment (i.e. 1 lost out of 10). Clearly describe Nature and Extent of damage. Show Actual cost of goods. Show all discounts, allowances & salvage. Indicate amount claimed.
 Description (50 Character Max)  Claim $
 Is the damaged freight repairable?
 If No, Why? 
 Freight Charges Claimed:  $ 
 Salvage Value
 Packaged Weight(lbs)    Total Claim(s)   $   
 Were outer containers damaged?
 No. of outer containers damaged    Extent of damage to outer containers  
 Name of individual notified of Loss / Damage    Carrier Affiliation    City / Branch Office  
 Date and time of notification
 Method of notification
 Date freight Inspected  
Check the appropriate supporting documents. Please note: you will be able to attach the supporting documents to an email after you submit this form. please scan and e-mail or otherwise attach to the email on the next page to prevent processing delays:

Remarks (Explain the absence of any pertinent documentation - 250 Character Max)

The following Certification Must be completed by the Claimant
The Foregoing statement of facts is herby certified to as correct
 Person Filing
 Address / P.O. Box
 Telephone No.
 City / State / Zip

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