Salesperson: _____________ StANDARD FORM FOR PRESENTATION RLI Order: _______________
OF LOSS AND DAMAGE CLAIM RLI Load: ________________
To: __________________________________________ _____________________________________________
Name of Carrier Date
_____________________________________________ _____________________________________________
Mailing Address Claimants Number
_____________________________________________ _____________________________________________
City, State, Zip Carriers Number
This Claim for $_____________________ is made against your company for ( ____Loss /_____Damage) in connection with the following described shipment:
_____________________________________________ _____________________________________________
Shippers Name Consignee's Name
_____________________________________________ _____________________________________________
Point Shipped From Final Destination
_____________________________________________ _____________________________________________
Name of Carrier Issuing Bill of Lading Name of Delivering Carrier
_____________________________________________ _____________________________________________
Date of Bill of Lading Date of Delivery
_____________________________________________ _____________________________________________
Routing of Shipment Delivering Carrier's Freight Bill No.
DETAILED STATEMENT SHOWING HOW AMOUNT CLAIMED IS DETERMINED
Number and description of articles, nature and extent of loss or damage, invoice price of articles, amount of claim, etc.
ALL DISCOUNT AND ALLOWANCES MUST BE SHOWN.
$
Total Amount Claimed $
The following documents are submitted in support of this claim:
Original Bill of Lading Consignee concealed loss or damage form
Original paid freight bill or other carrier document bearing notation Original invoice or certified copy
of loss or damage if not shown on freight bill Shipper's concealed loss or damage form
Carrier's Inspection Report Form (Concealed loss or damage) Other particulars obtainable in proof of loss or damage
claimed:
Note: The absence of any document called for in connection with this claim must be explained. When impossible for claimant to produce original
bill of lading, or paid freight bill, a bond of indemnity must be given to protect carrier against duplicate claim supported by original documents.
Remarks: ___________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________
The foregoing statement of facts is hereby certified as correct.
_____________________________________________ _____________________________________________
Claimant's Name Claimant's Address
_____________________________________________ _____________________________________________
Claimant's Phone Number Claimant's City, State & Zip
Reckart Logistics Use only
Insurance Carrier___________________________________ Insurance Phone: ___________________________________
Date Reported_____________________________ Date Resolved: _____________________________________
Deductible_______________________________ Resolution: ________________________________________
