STANDARD FORM FOR LOSS & DAMAGE CLAIM

Part 1
NOTICE TO CLAIMANTS

Claimants are requested to make use of the Landstar “Standard Form for Presentation of Loss and Damage Claim”
(part 2) when filing a formal cargo claim. Claims along with all supporting documentation must be timely filed with
the Landstar Operating Company checked on the face of the Claim and received by Risk Management Claim Services,
Inc., 13410 Sutton Park Dr., South, Jacksonville, FL 32224. Claims and all supporting documentation can also be
submitted electronically addressed to: claims@landstar.com or claims and all supporting documentation can be sent
via fax to: (904) 390-1244. Risk Management Claim Services, Inc., (RMCS) is the Landstar affiliate that facilitates
the processing of submitted claims. Your claim will be considered properly presented only when the information and
documents called for has, as far as possible, been supplied. All transportation charges must be paid in full before any
claim can be processed on behalf of the claimant. We will promptly acknowledge your claim in writing by mail. The
following important information should be given every consideration when making your claim:

1. The terms under which the property is accepted and transported by a carrier are stated on the bill of lading issued
by the carrier; also in schedules, tariffs and classifications issued or subscribed to by the carrier. Shipments
between the parties may also be subject to individually written and agreed upon transportation contracts or
agreements that may take precedent to the terms and conditions to the bill of lading contract terms and
conditions. Persons intending to file claims should, before doing so, examine the terms and conditions under
which the property being claimed was accepted and transported. Contract shipments, Intermodal shipments,
shipments of perishable or exempt commodities, air freight and or ocean carriage have claim filing time limits,
limitations of liability and other stipulations that are different than those of general commodities. We do not pay
consequential or special damages of any nature whatsoever. Loss to perishable commodities such as produce,
require a copy of the U.S.D.A. inspection to accompany any claim.

2. Carriers are bound by the provisions of law, and any deviation therefrom by the payment of claims before the
facts and measure of legal liability are established will render them, as well as the claimant, liable to fines and
penalties by law. Claimants have a legal obligation to mitigate the claim to its fullest possible extent. In
compliance with State Law we must inform you that the filing of fraudulent claims is unlawful.

3. In order that the carrier may have an opportunity to inspect goods and the packaging used, thereby properly
verifying the claim, any loss or damage discovered after delivery can be reported to the Cargo Loss Prevention
and Security Department by telephone at 800-872-9103, but in any event must be reported in writing to the
Cargo Loss Prevention Department, 13410 Sutton Park Drive, South, Jacksonville, FL 32224. Written report can
also be sent via fax to 904-390-4732 or by email to: cargolossprevention@landstar.com Notice must be made
within 15 days after receipt of goods by the consignee. Concealed loss and damage claims should be supported
by the inspection or survey form covering the joint inspection of the loss or damage by the party in possession
and the carrier’s designated representative. If the carrier waives the inspection in writing, the consignee must
make the inspection and record all information to the best of their ability pertinent to the cause and nature of the
loss or damage and take photographs of the package, packing used, etc. All claims must be supported by the
original invoice or an exact copy thereof, the original Bill of Lading and evidence of paid freight charges or suitable
indemnity in lieu. Repair claims must be supported with an itemized repair invoice reflecting actual out-of-pocket
costs and should show the number of labor hours, labor hourly rates charged and a list of parts and materials.

4. It is a common practice for manufacturers and others to ship large quantities to key points for warehousing and
later distribution to surrounding areas. In many instances, the original container is not opened and the contents
examined before re-shipment to final destination. When this practice is followed, it is impossible to determine
after delivery to final destination whether loss or damage of a concealed nature occurred before or after re-
shipping. Consignees can usually expedite processing of the claim by seeking the initial shipper’s and
warehouse’s cooperation in supplying copies of the necessary receiving and billing reference so that all of the
handling sites can be identified that provided transportation to the distribution point where loss or damage was
first discovered.

5. Claims on shipments originating from or destined to a foreign country may be subject to limitations of liability
different from that as stated in the carrier’s domestic Bill of Lading, tariffs or classifications in effect on date of
shipment. Shipments of general commodities originating out of a Province of Canada for instance, are subject to
a limitation of liability and have different claim filing time limits as provided by that Province and in most cases
are less than that of shipments originating within the United States. Mexican law provides that it is the
responsibility of the shipper or consignee in Mexico to provide the insurance on shipments while in Mexico and not
the carrier. Therefore, claims involving incidents occurring while the cargo is in Mexico should be made with your
insurance company. Claims on losses occurring in Mexico should not be made with Landstar as cargo liability for
same will not be accepted.

NOTICE TO CLAIMANTS Part 1 (R 09/10)

 STANDARD FORM FOR PRESENTATION OF LOSS AND DAMAGE CLAIM
(Please read the NOTICE TO CLAIMANTS page accompanying this form before filing claim)

Mail claim supporting documents to: Risk Management Claim Services, Inc., 13410 Sutton Park Dr, South, Jacksonville, FL 32224
E-Mail Claim with all supporting documents attached to: claims@landstar.com
Fax claim with all supporting documents to: (904) 390-1244

(Place a 5 check in front of the company below to which claim is being submitted)
† LANDSTAR EXPRESS AMERICA, Inc. † LANDSTAR GEMINI, Inc. † LANDSTAR GLOBAL LOGISTICS, Inc.
† LANDSTAR INWAY, Inc. † LANDSTAR LIGON, Inc. † LANDSTAR RANGER, Inc. † LANDSTAR SUPPLY CHAIN SOLUTIONS, INC.

This claim for $___________________ is submitted to the above checked company for - (check box that applies)
† Loss or † Damage in connection with the following described shipment:

Ship Date: __________ Waybill / Bill Lading No.:_______________ Claimant’s Claim No.:___________________

Landstar Freight Bill No.:______________________________ Date Delivered:______________________________

Shipper Name:_____________________________________ City / State: __________________________________

Consignee Name:___________________________________ City / State: __________________________________

Detailed statement showing the quantity and the product claimed and an itemized listing of how the amount claimed was determined.
All trade allowances and invoice discounts must be shown. Use a separate page if necessary to list additional items claimed.
Quantity Product Description and Explanation of Charges Claimed Amount (USD)

NMFC Item Number of commodity claimed: ▼ ▼ Total Amount of Claim (USD)▼

The following documents are attached to this claim as support (check all that apply):
Original Bill of Lading Original Invoice or Certified Copy Itemized Repair Invoice Paid Freight Bill Inspection
NOTE: The absence of any document called for in connection with this claim must be explained. When impossible for claimants to produce the Original
Bill of Lading or paid freight bill, a bond of indemnity must be given to protect the carrier from a duplicate claim supported by original documents.
Proof of Loss Statement may be deemed as a required document in a claim involving a shortage, theft or pilferage.
INDEMNITY AGREEMENT
In the absence of the Original Bill of Lading and/or Original Freight Bill, we agree to hold Risk Management Claim Services, Inc. and CARRIER, to whom
this claim is presented, and any other participating carrier harmless and indemnified against any and all lawful claims which may be made against it or
them arising out of the same shipment and will pay to the said carrier and any participating carrier(s) any losses, damages, costs, counsel fees or any
other expenses which they or any of them may suffer or pay by reason of payment of our claim, herein described, without the surrender of the
Original Bill of Lading or Original Freight Bill, as such was not provided and/or cannot be located.
ASSIGNMENT OF CLAIM
SHIPMENTS BROKERED BY LANDSTAR:, CLAIMANT, by signature below, does hereby assign and transfer to the Landstar company checked above to
which claim is made and to RISK MANAGEMENT CLAIM SERVICES, INC., (RMCS) all interest in property for which a payment may be made to the
extent of that payment, and assigns and transfers to that Landstar company checked above and RMCS any and all claims and demands against any
other party, persons, property or corporation, arising from or in connection with such loss and damage and RMCS is hereby subrogated in the place of
Claimant to the extent of the amounts being claimed.

The foregoing statement of facts is hereby certified as correct.

___________________________________________________________
Claimant’s Company Name For Correspondence or Payment Information
Today’s Date: ______________________________
X____________________________________________________
Signature of Individual Making Claim
Claimant’s Phone No. ________________________________________
__________________________________________________________________
Print Name and Title / Position
Email Addr:_______________________________________
______________________________________________________________________
Mailing Address Where Correspondence or Payment Should Be Mailed

_______________________________________________________
City, State, Zip - Country
Landstar Claim Form Part 2 (Rev. 05/12)