Coated and SC Papers ::

	Contact Information: Phone: 800-443-7617 Fax: 800-570-5689
Please fill out the form below. Once your information has been submitted, you and a Transit Service Representative will receive a copy of the claim via email. The claim will be sent to you in a PDF format that is readable with Adobe Acrobat Reader.

(*) Required Field

Contact Information:

Company Name: *
Contact Name: *
Address 1: *
Address 2: *
City: *

State: *
Zip/Postal Code: *
Phone Number: *
Fax: *
E-Mail: *

Order Information:

Mill/Sales Order Number:
Car/Trailer Number: *		B/L Number: *
Customer Claim Number:

Signed Delivery Reciept:

Yes

N/A

Required for Motor Carrier(s)

Date RR Notified:
Waived By:

Product Information:

Number Of
Units *

Damaged
Weight *

Roll/Skid No.
or Carton Stock No.

Product Description

Price
(If Avail)

Amount

Sub-Total Amount:

[+] No. of Photos:

@ 1.00 Each

[+] Rework Cost:

[+] Handling Cost:

[-] Salvage Allowance:

Total Claim Amount:

At Least One Box Must be Checked
Damage Type:
	Water Damage - Visible	Loss/Shortage	Collapsed Units
	Water Damage - Concealed	Accident/Derailment	Shifted Product
	Crushed Cores - Visible	Gouge	Fire
	Crushed Cores - Concealed	Foreign Object/Substance	Roll Chafing
	Edge Damage/Torn Edges	Other (Please Specify)

Check All Documents Sent
Documentation Required:
	Signed Delivery Reciept/Bill of Lading	Invoices (If Available)
	Pictures/Diagrams	Shipping Tally/Manifest

At Least One Box Must be Checked
Damaged Product Status:
	Released to Carrier	Repaired/Strip Waste
	Hold for Carrier Pickup	Sold/Salvaged Allowance Given

Location of Damage:
On Product		In Trailer		In Rail Car
	Top		Nose		A-End
	Sides		Doors		B-End

Condition of Load:

Condition of Dunnage:

Inflated

Deflated

Burst

Blocking/Bracing:

Intact

Broken

Condition of Equipment:

Protruding Object

Dirty

Door/Walls Bulged

Holes in Vehicle:

	No		Yes	If yes, please check where holes were located:
	Nose		Ceiling		Walls		Floor		Around Door Seals

Facts Relating to Damage:

Assignment of Claim:

Company Name: *
Title Holder and Assignor:

Hereby gives over and assigns to Verso Paper Company (herein after called the "assignee"), all rights, titles, and interests which has or may have in any claim against the transportation companies for the recovery of money or for other redress on account of loss of or damage to the shipment or shipments described above. Said assignor does hereby give unto the said assignee full and complete authority to settle assignor’s claim, and to receive payment in settlement of the aforesaid claim.

Note:

If this is a truck or piggyback shipment, please
note damages and have the driver sign the
delivery reciept.

(Rail shipments require notification of damages)

Claim Documentation:

The supporting documentation of the claim
will be sent via: *

	E-Mail		Fax		Mail

(*) Required Field