Gencom - Claim for Loss or Damage

CLAIM FOR LOSS OR DAMAGE
SEE INSTRUCTIONS BELOW
Gencom Transportation, Inc				Date
P. O. Box 16672
Denver, Co 80216-0672				Claimant's Reference No.:
Phone 303-388-8532 Fax 303-388-8539
	PART A-NOTICE OF CLAIM

This claim for $____________________is made against______________________for [ ] loss [ ] damage, in connection with the following
shipment:

Shipment Date	Freight Bill #		Delivering Carrier Name			Freight Bill #

Shipper	City	Consignee				City

Detailed statement showing how amount claimed is determined:____________________________________________________________________





		Total Amount Claimed:					$


Remarks:					Name of company filing claim:
					x
Disposition of Salvage:					Handwritten signature of Official

I/We certify the foregoing statement of facts is true and correct:					Address

					City, State, Zip

PART B-VERIFICATION OF LOSS STATEMENT
This is to certify that a shortage of_________________________________________, from_______________________________________
to______________________________________, covered by Carrier's PRO No._____________________, dated______________, has not been
received from any source to date, and in the event said shortage is received, we hereby agree to notify________________immediately,
advising the name of the carrier delivering and their billing reference. We further agree to return the merchandise to the above named carrier
named carrier if requested to do so, or reimburse said carrier the amount paid in settlement of the claim covered by this shortage. understand that the
We fully understand that the Interstate Commerce Act provides fines for anyone guilty of filing a false or fraudulent claim on an
interstate shipment and with that knowledge hereby cerfify that the above shortage still exists and recognize our obligation to inform
the above carrier in the event that the merchandise now short is subsequently delivered to us by any means.

					Consignee's Company Name
					x
					Handwritten Signature of Official

					Title
PART C-Guarantee in Lieu of Original Bill of Lading of Original Paid Freight Bill
The undersigned hereby indemnifies the carrier against any loss which might arise from the payment of this claim without the original bill of lading
and/or the original paid freight bill:
					x
					Handwritten Signature of Official

INSTRUCTION FOR FILLING OUT THIS FORM

Upon noting damage to your goods, you must contact the carrier immediately for an inspection. Then you must file a written freight claim. Mail the original signed copy of this form to the carrier at the address at the top this form.


[ ] Fill in date, your claim number, and fill out & sign PART A completely.
[ ] Attach the original invoice or a photocopy of the original invoice.
[ ] In the event of shortage or pilferage, PART B MUST be executed by the Consignee.
[ ] Attach original bill of lading, paid freight bill, or read and sign PART C.
[ ] Attach INSPECTION REPORT to your damage claim.
[ ] Attach any bills covering repairs or any other supporting papers you have.