Ticket NumberThis claim is made against above named carrier for* Loss Damage Other In connection with the following described shipment: please be advised claims must be filed within 72 hours of delivery in order for claims to be consideredShipper NameShipper Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Recipient Name First Last Destination Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Supporting Document CheckList* Claim Form Deluxe Ticket Pictures of Damaged Item Original Invoice of Item Inspection Report Statements from Driver and Dispatcher Delivery Information:Delivery Date Delivery Time : HH MM AM PM Signed for By:Detailed Statement form Claimant:*Claimant InformationContact Name*Phone#*Company NameClaimant Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code * I have answered to the best of my knowledge and have provided the required supporting documents I understand incomplete packets and claims reported after 72 hours may not be considered for processing. Claimant Signature*Enter NameUpload File 1Upload File 2Upload File 3Upload File 4 This iframe contains the logic required to handle AJAX powered Gravity Forms.