Claim Form Claim Form Presentation of Loss and Damage Claim First Name* Last Name* Email* Company Name* Claimant's Claim No:* Date Prepared:* Address:* Zip Xpress Pro No.:* Freight Bill Date:* Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Ship Date* MM slash DD slash YYYY Delivery Date* MM slash DD slash YYYY Claim Amount Please Select* Visual Damage Shortage Shipper:* Consignee:* Origin:* Destination:* Detailed Statement Showing How Amount Claimed For is Determined:QuantityDescriptionAmount Please include quantity, item #, nature and extent of the loss. Zip Xpress does not participate in concealed damage claims. All discounts and allowances must be shown. Please click the PLUS button on the right to add more rows.Applicable Freight Charges* Total Amount Claimed:* Documents needed in support of Claim Original or copy of paid freight bill Original invoice or certified copy Carrier's inspection report if inspection done (for damage claims only) Repair bill or certified copy if repaired( showing material used & labor rate per hr) Weight of damaged or lost items Please check the fields in which you have provided the appropriate document for (see below). Any claim received without this document is subject to denial based on NMFC Item #300110. Original or copy of paid freight bill Drop files here or Select files Accepted file types: jpg, png, pdf, jpeg, docx, Max. file size: 10 MB, Max. files: 5. Original invoice or certified copy Drop files here or Select files Accepted file types: jpg, png, pdf, jpeg, docx, Max. file size: 10 MB. Carrier’s inspection report if inspection done (for damage claims only) Drop files here or Select files Accepted file types: jpg, png, pdf, jpeg, docx, Max. file size: 10 MB. Repair bill or certified copy if repaired (showing material used & labor rate per hr) Drop files here or Select files Accepted file types: jpg, png, pdf, jpeg, docx, Max. file size: 10 MB.
