Hazardous Material Cargo Claim Form
Claimant Information
Name
Company
Email
Phone
Address
City
State/Province
ZIP/Postal Code
Cargo & Incident Details
Date of Incident
Location of Incident
Bill of Lading Number
Shipment Reference #
Hazardous Material Details
Material Name
UN Number
Quantity Involved
Package Type
Nature of Claim
Type of Claim
Damage
Loss
Contamination
Other
Claim Amount
Description of Incident & Claim
Supporting Documents
List attached documents
Declaration
I declare the above statements are true and complete: