Claim Form

Sheet1Claim Form(Claim#)This number should reflect the number of the invoice billing ADL.Please provide full address, city, st, ZIP, and phone number.Please provide full address, city, st, ZIP, and phone number.Original Ship DateThis Claim is submitted for:LOSSDAMAGEOriginal Invoice #Please Check OneClaim Details(part #'s, description of the parts being claimed, amount claimed)Part #DescriptionAmount ClaimedTotal Amount ClaimedLost Parts or Lost/Uncollected COD'sCheck OneMissing FreightRemarks and Description from Claimant:Missing Return FreightUncollected CODDamaged PartsCheck OneOVisible Shipping DamageRemarks and Description from Claimant:Concealed DamageWater DamageThe foregoing statement of facts is hereby certified as correct:(Signature of claimant)For ADL Use OnlyApprovedComments:DeniedDirections1 - All claims must have an attached copy of the original shipping invoice and an invoice billing ADL.2 - All claims must be filed within 10 business days of the date of shipment. Any claims filed after this grace period will bedenied and returned to the shipper.3 - Any claims for lost or damaged freight will be denied if a signature is obtained at the time of delivery.4 - ADL will not be responsible for any checks provided by a customer unless ADL is specifically asked to collect cash at thetime of delivery. If authorization is given by an employee of the shipping location, ADL will not be responsible.5 - There should be only one claim form per shipment.6 - ADL will not be responsible for any unsecure/unprotected stops.IE: Any stops that are dropped at night without a secure location or protection from the elements.