FMCSA Claim Form

FMCSA Claim Form

Federal Motor Carrier Safety Administration (FMCSA) Claim Form – Freight Broker/Freight Forwarder Bond

This form is for the submission of a claim on a freight broker/freight forwarder bond. If you are a shipper or carrier and you are owed money by a freight broker/freight forwarder, please complete the following claim form.

All fields marked with an asterisk* are required.

    Have you communicated with the broker in any way in order to try and resolve this issue?*

    Claimant Information

    The company/person filing the claim is considered the "Claimant." The contact information below should be that of the Claimant. The provided information will be used to contact you regarding the claim.

    An MC# (Motor Carrier #) is given to companies required to have Interstate Operating Authority in addition to a DOT #. All companies that Transport federally regulated commodities owned by others or arranging for their transport, (for a fee or other compensation, in interstate commerce) are required to have one. The MC number begins with the letters MC followed by a space and 5 numbers.

    Broker Information

    The company/person responsible for facilitating the transaction and for issuing payment upon completion of the work or service provided is the "broker." The provided information should be that of the Broker.

    Claim Information

    Please provide as much information as possible.

    Upload the following documentation

    The rate confirmation sheet governs the services and payment issuance between the freight broker and carrier.

    The executed broker/carrier agreement is the contract between the broker and the carrier.

    A bill of lading is a legal document issued by a carrier to a shipper that details the type, quantity, and destination of the goods being carried.

    A proof of delivery is a signed confirmation of what is listed in the bill of lading, post-delivery.

    The invoice outlines the cost for the service provided.

    Copies of any communication between the Claimant and Broker regarding this matter.

    Contact information for FMCSA claim related matters:

    Email: [email protected]
    Phone Number: (973) 200-6497
    Fax Number: (973) 339-5834
    Mailing Address: 1 Baxter Way, Suite 130, Westlake Village, CA 91362
    Attn: James Portman, Chief Legal Officer

    Please have the following available:

    Claimant Information (contact name, company (claimant) name, address, email, phone, carrier no.)

    Principal Information (principal company name, principal address, USDOT number, MC no., bond no.  (if known), invoice no., payment due date, amount owed, whether a demand been made on the principal or not)

    Documentation (rate confirmation, executed broker/carrier agreement, bill of lading (BOL), proof of delivery (POD), invoice, demand/correspondence

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