Submit Claim with Shelba D. Johnson Trucking, Inc.

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TO:	Shelba D. Johnson Trucking, Inc.
	P.O. Box 7287 High Point, NC 27264
PH: FAX:	(336) 476-2000 (336) 476-9310

11/20/2008
DATE

CLAIMANT NUMBER*

CARRIERS PRO NUMBER*

THIS CLAIM FOR $0.00 IS MADE AGAINST YOUR COMPANY FOR

LOSS(ES)
DAMAGE(S)

* IN CONNECTION WITH THE FOLLOWING SHIPMENT.

Shipper Name*

Shipper Address*

City / State / ZIP*

Consignee Name*

Consignee Address*

City / State / ZIP*

IF SHIPMENT WAS RECONSIGNED EN ROUTE, STATE PARTICULARS:

DETAILED STATEMENT SHOWING HOW AMOUNT OF CLAIM IS DETERMINED

Description of Claim (PLEASE GIVE ITEM NUMBER, COMMODITY DESCRIPTION, NUMBER OF PIECES CLAIMED, AMOUNT BEING CLAIMED. ALL DISCOUNTS AND ALLOWANCES MUST BE SHOWN)	Amounts(s)

NMFC Item No:

Total Amount of Claim: $0.00

Original Bill of Lading Original invoice or certified copy Consignee concealed loss or damage form Carrier's Inspection Report Form (concealed loss or damage)	Original paid freight bill or other carrier document bearing notation of loss or damage if not shown on freight bill Shipper's concealed loss or damage form Other particulars obtainable in proof of loss or damage claimed (list below):
Other:
(NOTE: The absence of any documents called for in connection with this claim must be explained. When impossible for claimants to produce original bill of lading or paid freight bill, a bond of indemnity must be given to protect carrier against duplicate claim supported by original documents.) INDEMNITY AGREEMENT In the absence of the Original Freight Bill and/or Original Bill of Lading, we agree to hold the above named 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 rising out of the same shipment and will pay to the said carrier and any participating carrier(s), all 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 Freight Bill or Bill of Lading, as such was not provided and/or cannot be located.

Note: If the section below is not filled out completely, it is very possible that your claim WILL NOT be processed.

The foregoing statement of facts is hereby certified and correct.

PERSON FILLING OUT CLAIM FORM*		COMPANY NAME*
CLAIMANT TITLE*		COMPANY ADDRESS*
SIGNATURE* (Typing Name Signifies Signature)		PHONE NUMBER*
November 20, 2008 TODAY'S DATE		FAX NUMBER
	Send Copy? EMAIL ADDRESS*

ATTACHMENTS