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1/09
Claim Form
For lost or damaged U.S. or international shipments
Sender or Shipper’s Name / Contact FDX EXP/OAKLAND- EMERYVILL Recipient’s or Consignee’s Name / Contact ROB WORTH
Company Company
Address 1600 63RD ST Address 87 MAIN ST
City EMERYVILLE State / Province CA City CANTON State / Province NC
Country US ZIP / Postal Code 946082033 Country US ZIP / Postal Code 28716
Phone 5105478503 Fax Phone Fax
E-Mail E-Mail
Declared value
(The value declared on the Declared value for customs
shipment when tendered to FedEx) $ (International shipments only) $
Merchandise value
(Original purchase value and/or cost to repair) $ 350
FedEx pack & ship fee $ 31.67 Freight charge $ Total claim / C.O.D. amount $
Customer remarks
If your claim is filed for damage, and mitigation through repair or allowance is not possible, please explain why and provide contact information for salvage pickup.
Salvage Salvage should be held until investigation of the claim is complete.
Claimant Information ! I accept that the foregoing statement of facts is hereby certified as correct. Date
Signature (for fax or mail) Internal Reference No.
Claimant’s Name (please print)
Claimant’s Address Phone
City State / Province
Country ZIP / Postal Code
E-Mail Fax
E-mail, Fax or Mail Please return the completed form and required Proof of Value documentation (invoice and/or receipt) to:
E-mail: file.claim@fedex.com | Fax 1.877.229.4766 | FedEx Cargo Claims Dept. P.O. Box 256 Pittsburgh, PA 15230
SUBMIT
31581PL 1/09