CARGO LOSS NOTICE
DATE/TIME REPORTED
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INSURED NAME:
POLICY INFO:
*
DATE/TIME OF LOSS:
AM
PM
PREVIOUSLY REPORTED:
ADDRESS OF INSURED:
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CONTACT PERSON:
HOME PHONE NUMBER:
BUSINESS PHONE NUMBER:
WHERE TO CONTACT
WHEN TO CONTACT
CLAIM#:
LOCATION OF LOSS:
Loss
DESCRIPTION OF LOSS:
POLICE/FIRE DEPT. WHICH REPORTED:
AMOUNT OF ENTIRE LOSS:
DESCRIPTION & LOCATION OF CARGO (FOR INSPECTION PURPOSES):
AMOUNT OF INSURANCE & DEDUCTIBLES:
REMARKS/OTHER INSURANCE (list companies, policy numbers, coverages & policy amounts)
Parties
NAME OF PARTY
TYPE^
PHONE #
ADDRESS
Type
^The various types of parties are:
Brokered Load Carrier (BLC)
Consignee (CON)
Insured Carrier (IC)
Insured Driver (ID)
Other Carrier (multiple shipments) (OC)
Shipper (SH)
Witness (W)
Tow Company (TC)
USDA Inspector (USDA)
State Food Inspector (SFI)
Police Department (PD)
Fire Department (FD)
Reporting
REPORT COMPLETED BY:
INSURED
AGENT/BROKER
CLAIMS REPRESENTATIVE
*
indicates a required field