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Claimant Contact Name:
Claimant Company Name:
Claimant Address:
Claimant City: State: Zip:
Claimant Telephone: Claimant Fax:
Claimant email:
Claim Amount: Your Reference or Claim #
Claim for: Shortage Damage Other
Freight Bill #: Delivery Date:
Shipper Name:
Consignee Name:

Please enter a detailed statement showing how amount claimed is determined. (Number and description of articles, invoice price of articles, etc. All discount and allowances must be shown.)

Also send us a copy of the original invoice and any additional supporting documentation. Clearly mark your supporting documentation with the "Freight Bill #" and/or "Your Reference or Claim #" as entered above. Documentation may be faxed to Severance Trucking at (978) 275-3811, or emailed to mike@severancetrucking.com.