CLAIM FORM

FORMULIR KLAIM

Data Resi Sentral Cargo :

1. Receipt Of Number : ………………………………………………………………
Nomor Resi
2. Sender : ……………………………………………………………….
Nama Pengirim
3. Receiver : ……………………………………………………………….
Nama Penerima
4. Origin : ……………………………………………………………….
Asal
5. Date Delivery : ………………………………………………………………
Tanggal Pengiriman
6. Destination : ………………………………………………………………
Tujuan
7. Recipient Date : ……………………………………………………………….
Tanggal Penerima
8. Weight : ………………………………………………………………
Berat Asli
9. Type Of Goods : ………………………………………………………………
Jenis Barang
10. Number Of Collies : ………………………………………………………………..
Jumlah Koli
11. Via : ………………………………………………………………
Jalur

Loss Details / Detail Kerugian :

1. Date Of Loss : ……………………………………………………………………
Tanggal Kerusakan/kehilangan
2. Item Condition : Lost Some Partially Damaged
Kondisi Barang Lost Full Completely Damaged

3. Amount Of Loss : …………………………………………………………………….

Nominal Kerugian
Customer Base for Claims related to lost or damaged goods:
Dasar pelanggan untuk klaim terkait dengan barang yang hilang atau rusak
………………………………………………………………………………………………………………………..
……………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………

Documents Attached / Dokumen Terlampir :

(Contoh:Invoice,Nota,Foto,Video,Resi)
1. ………………………………………………………………………………………………………………

2. ………………………………………………………………………………………………………………

3. ………………………………………………………………………………………………………………

4. ………………………………………………………………………………………………………………

5. ………………………………………………………………………………………………………………

6. ………………………………………………………………………………………………………………

Declaration / Pernyataan :
I/We declare that the above statement is made truthfully
Saya / Kami menyatakan bahwa pernyataan diatas dibuat dengan sebenar-benarnya

Jakarta, ......................... 2024

Signature / Stamp :
Tanda Tangan / Stempel :

Name :
Nama