Claimant Information

Company (claimant) name

Address

Email

Phone

Your carrier's MC#

Principal Information

Company name

Address

USDOT number

The MC# of the freight broker

Bond no.

Invoice no.

Load no.

Payment due date

Amount owed

A demand been made on principal

Upload the following documentation

Rate confirmation

Executed broker/carrier agreement

Bill of lading (BOL)

Proof of delivery (POD)

Invoice

Demand/correspondence