Name & Address of the consignors*

Name & Address of the consignees

Nature of goods

Number and date of the carrier's receipt

Place of dispatch

Place of destination

Date of arrival of the consignment at destination if by streamer, dates of landing and clearance

Date of dispatch to interior destination, if any

Date of taking delivery at the final destination

Reason for delay for taking delivery at final destination, if any

Date when loss or damaged noted

Total number of cases and/or packages dispatched with marks if any

Number taken delivery of

Number not delivered by the Carriers (Steamer agents or land carriers)

Full details of the condition of the cases and/or Packages taken delivery of

If damaged in transit, was steamer survey held or open delivery taken? If so, attach certificates from the carriers

If claim has not been lodged, state the reason for the same

Sound market value of goods on date of arrival

Duty payable on sound goods

Further remarks

Original Insurance Policy and/ or Certificate duly endorsed

Complete invoices together with supplementary

Copy of the Bill of Lading

Copies of correspondence exchanged with the carriers Port Trust together with their replies in original

Steamers survey report

Carriers Certificate (Rail, Lorry, Post and/or Air)

Address

Particulars of goods

Nature of loss

Estimate of repairs and/or replacements