htmlTitle (html-block)
HTML Title
claimInTheAmountOf* (text, input)
Claim in the amount of $
radioButtons1* (select, radio)
is hereby filed for (check one):
claimantsClaimNo* (text, input)
Claimant’s Claim No.:
billOfLadingNo (text, input)
Bill of Lading No.:
carrierProNo (text, input)
Carrier Pro No.:
hrLine1 (html-block)
HR Line 1
htmlSubheading1 (html-block)
HTML Subheading 1
nameFirst* (text, input)
First Name:
nameLast* (text, input)
Last Name:
address1 (street-address, horizontal)
Address:
hrLine2 (html-block)
HR Line 2
shipper* (text, input)
Shipper:
consignee* (text, input)
Consignee:
emptyBlock (html-block)
empty block
address2* (street-address, horizontal)
Address:
address3* (street-address, horizontal)
Address:
hrLine3 (html-block)
HR Line 3
htmlBody1 (html-block)
HTML Body 1
wereArticles* (select, radio)
Were articles:
weightOfLostOrDamagedArticle* (text, input)
Weight of lost or damaged article:
descriptionOfLostItem* (text, input)
Description of lost item:
pieces* (text, input)
Pieces:
amountClaimed* (text, input)
Amount claimed $
descriptionOfLostItem2 (text, input)
Description of lost item:
pieces2 (text, input)
Pieces:
amountClaimed2 (text, input)
Amount claimed $
descriptionOfLostItem3 (text, input)
Description of lost item:
pieces3 (text, input)
Pieces:
amountClaimed3 (text, input)
Amount claimed $
descriptionOfLostItem4 (text, input)
Description of lost item:
pieces4 (text, input)
Pieces:
amountClaimed4 (text, input)
Amount claimed $
htmlSpacer (html-block)
HTML Spacer
totalAmountClaimed* (text, input)
Total amount claimed $
hrLine4 (html-block)
HR Line 4
htmlBody2 (html-block)
HTML Body 2
selectables1 (select-multiple, checkbox)
Documentation of transportation contract:
selectables2 (select-multiple, checkbox)
Documentation that loss or damage occurred:
selectables3* (select-multiple, checkbox)
Documentation of value/amount claimed:
selectables4 (select-multiple, checkbox)
Other documents to support claim:
htmlBody3 (html-block)
HTML Body 3
hrLine5 (html-block)
HR Line 5
remarks (text, textarea)
Remarks:
fileUpload (file-upload, file)
File Upload
htmlBody4 (html-block)
HTML Body 4
claimantsName* (text, input)
Claimant’s Name:
phoneNumber* (phone-number)
Telephone No.:
faxNumber* (phone-number)
Fax No.:
emailAddress* (email)
Email Address: