Cargo Loss Form

Please fill out the form below in order for us to expedite your case:

	Client:			Adjuster:
	Address:			Telephone:
	Assured:			Contact:
	Address:			Telephone:
	Policy/Claim No.
	Date of Loss:			Type of Loss:

	Prior Claims/Types of Loss:

	Shipper:
	Consignee:
	Carrier:

	If Carrier is a truck, need drivers name, vehicle make & license:

Location of Incident/Accident/Theft:

	Address:
	Contact:			Telephone:
	Police Agency:			Contact:
	Other Adjusters or Surveyors involved:

	Explanation of Loss: