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Customer Claims

*Fields required.


Item(s) List

*Invent. #
Description of article lost or damaged
Description of the damage to (or loss of) item
Date Aquired
Orig. Cost
Amount Claimed

The submitter hereby makes a solemn oath to the truth of the statements contained herein, and exhibits attached hereto, and that no material fact is withheld that should be included in this report.

For the purpose of obtaining money on the above claim I hereby demand:

which is to be considered as a full release and discharge from any and all claims and demands accruing prior to this claim, and particularly from any and all claims and demands rising out of the transportation described in the foregoing statement. I understand that this is my full and final claim.