Claim Entry Form - Loss & Damage

Pro # Date:
Customer Reference # Date:
Claim Type:
Delivery Date:

Addresses:
Claimant Shipper Consignee




The Custom Companies

135 N. Railroad Ave.

Northlake, IL, 60164

Not Required

.

., IL, .

Not Required

.

., IL, .
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Products:
Part # Part Description Quantity Unit Weight Unit Cost Line Total
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Additional Costs:
Type Description Amount
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Total Weight of Claim: Total Amount of Claim:
Documents: (Required Documents: Pro #, Sales Invoice)
Total Size: 0 KB
Document Type Document Id Date Of Attachment
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    Summary of Claim:
    Claim Contacts:
    Name Title Phone # Email
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    Contact Info:

    Any questions, please contact The Custom Companies, Inc. at
    EMAIL: Claims@customco.com

    Carrier QuickClaim (1.0.2)
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