Address:

Contact:

Claimants Claim #:

Phone:

Fax:

E-mail:

"Intent to Claim"

Formal Claim

The amount of

is hereby filed against Vision Transportation Inc. for:

Product Description:

Shipper:

Origin:

Date of Pickup:

Consignee:

Destination:

Date of Delivery

Customer P.O./Order

Vision Trip Order

Briefly describe what the claim represents, and indicate how the amount of the claim was calculated.

If the claim involves damaged goods, please check one or more of the following:

To avoid a delay in processing your claim, please attach appropriate documentation as follows:

Claimants Name

Date