DD FORM 1844, MAY 2000 7. LOST OR DAMAGED ITEMS

AMOUNTALLOWED1. NAME OF CLAIMANT(Last, First, Middle Initial)3. PICK-UP DATE (YYYYMMDD)LIST OF property AND CLAIMS ANALYSIS CHART( ITEMS 14 through 31 to be filled out by Claims Office)2. CLAIMANT'S INSURANCE COMPANY (If applicable)a. NAME b. POLICY DELIVERY DATE (YYYYMMDD)14. ORIGIN CONTRACTOR17. 2ND CONTRACTOR21. CLAIM NUMBER22. NET WT/MAX CAR15. INVENTORY DATE (YYYYMMDD)18. EXCEPTION SHEET DATE(YYYYMMDD)23. GBL NUMBER24. LOT LOST OR DAMAGED ITEMS (Describe the item fully, including brand name,model and size. List the nature and extent ofdamage. If missing, state "MISSING.") ORIGINAL COST11. AMOUNT CLAIMED a. Repair Cost10. MM/YYYYPURCHASED(or)b. ' REMARKS13. TOTAL $30. TOTAL AMOUNT ALLOWED$31. THIRD PARTY LIABILITY$$DD FORM 1844, MAY 2000 PREVIOUS EDITION IS

AMOUNT ALLOWED 1. NAME OF CLAIMANT (Last, First, Middle Initial) 3. PICK-UP DATE (YYYYMMDD) LIST OF PROPERTY AND CLAIMS ANALYSIS CHART (Items 14 through 31 to be filled out by Claims Office)

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Transcription of DD FORM 1844, MAY 2000 7. LOST OR DAMAGED ITEMS

1 AMOUNTALLOWED1. NAME OF CLAIMANT(Last, First, Middle Initial)3. PICK-UP DATE (YYYYMMDD)LIST OF property AND CLAIMS ANALYSIS CHART( ITEMS 14 through 31 to be filled out by Claims Office)2. CLAIMANT'S INSURANCE COMPANY (If applicable)a. NAME b. POLICY DELIVERY DATE (YYYYMMDD)14. ORIGIN CONTRACTOR17. 2ND CONTRACTOR21. CLAIM NUMBER22. NET WT/MAX CAR15. INVENTORY DATE (YYYYMMDD)18. EXCEPTION SHEET DATE(YYYYMMDD)23. GBL NUMBER24. LOT LOST OR DAMAGED ITEMS (Describe the item fully, including brand name,model and size. List the nature and extent ofdamage. If missing, state "MISSING.") ORIGINAL COST11. AMOUNT CLAIMED a. Repair Cost10. MM/YYYYPURCHASED(or)b. ' REMARKS13. TOTAL $30. TOTAL AMOUNT ALLOWED$31. THIRD PARTY LIABILITY$$DD FORM 1844, MAY 2000 PREVIOUS EDITION IS