Filing Date:

Claimant

Claimant:*

Company Name:*

Address:

Phone Number:

City:

State:

Zip:

Email Address:*

Shipper

Shipper:*

Address:

City:

State:

Zip:

Consignee

Consignee:*

Address:

City:

State:

Zip:

Other Information

Claimant Reference #:*

Date of Delivery :

Waybill/Claim #:*

Claim Information

Noted Damage Concealed Damage Shortage

Damaged goods can be used for an allowance of $

Damaged goods can be repaired for $

Damaged goods are located at

Damaged goods are not available (explain)

Other (explain)

Item Description

Pieces

Weight

Used

Description

Amount Claimed ($)

The following documents must be submitted to support this claim:

Original Vendor's Invoice, verifying amount of claim.
Legible copy of Freight Bill or original paid freight bills if available.
Original Bill of Lading.
Invoice for repair, if applicable.
Invoice for materials purchased to complete repair, if applicable.
When shipment is damaged, include photos or written verification of damage.
Packing List.

By submitting this form you, the claimant, certifies the forgoing information to be correct, and agrees to indemnify the carrier against loss in the event the original Bill of Lading and/or original Freight Bill are not submitted.

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You may also submit Claims Forms or other correspondence regarding this matter to:

Pegasus Logistics Group, Inc.
Attn: Claims
306 Airline Drive, Suite 100
Dallas, TX 75019
Fax: +1 469-671-0349
Email: claims@plg.cc

Errors

Customer Claim Form