Please complete this detailed intake form to submit a formal freight billing dispute, freight claim (loss/damage), or accessorial fee audit request. Providing complete information and attaching required supporting documentation allows our logistics accounting, carrier compliance, and claims review teams to thoroughly investigate your account, audit line-item freight charges, and resolve discrepancies efficiently.
Claimant / Company Name
Account / Customer ID Number
Primary Contact Name & Title
Contact Phone Number
Primary Email Address
Corporate / Billing Address
City
State / Province
Postal / Zip Code
Country
Claimant Role
Shipper (Origin)
Consignee (Destination)
Third-Party Logistics (3PL)
1. Mode of Transportation
Less-Than-Truckload (LTL)
Full Truckload (TL)
Air Freight (Domestic / International)
Ocean Freight (FCL / LCL)
Intermodal / Rail
Parcel / Express Courier
Other:
2. Shipment Identifiers & Tracking Information
Bill of Lading (BOL) Number
Carrier Name / SCAC Code
Carrier PRO / Tracking Number
Purchase Order (PO) Number
Pickup / Origin Date
Delivery / Destination Date
1. Financial Summary
Total Carrier Invoice Billed Amount
Contracted / Quoted Rate Amount
Total Disputed Amount in Contention
Uncontested Amount Paid / Being Paid
2. Primary Dispute Classification (Select all that apply)
Unauthorized Accessorial Surcharges: Billed for unrequested services (e.g., liftgate, residential delivery, detention, layover, limited access fees).
Freight Class / Re-Sizing Adjustment (Reweigh/Reclass): Carrier adjusted National Motor Freight Classification (NMFC) code, density calculation, or dimensional weight without verification.
Rate Quote Mismatch: Billed rate differs from written rate quote, contract tariff, or spot quote agreement.
Freight Loss or Physical Damage Claim: Cargo was lost in transit, damaged upon arrival, or delivered short.
Late Delivery / Service Failure Surcharge: Billed full freight charges despite missed guaranteed delivery window or contract breach.
Duplicate / Overlapping Invoice: Billed multiple times for the same PRO number, shipment leg, or fuel surcharge.
Other:
Statement of Dispute & Timeline
Please describe the specific shipment circumstances, pickup/delivery timeline, driver interactions, or reasons why this charge/claim is inaccurate:
1. Was a delivery receipt signed with notation of damage, shortage, or driver delay?
Yes (Notated on Proof of Delivery)
No (Clear Delivery Receipt)
Concealed Damage / Discovered Later
2. Accessorial / Discrepancy Log (If applicable, complete the table below)
Disputed Fee / Line Item | Billed Charge ($) | Expected Charge ($) | Driver/Terminal Reason Given | Supporting Evidence Attached | ||
|---|---|---|---|---|---|---|
A | B | C | D | E | ||
1 | ||||||
2 | ||||||
3 | ||||||
4 | ||||||
5 | ||||||
6 | ||||||
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8 | ||||||
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10 |
To ensure a thorough audit, please attach all relevant documentation. Incomplete submissions may delay investigation.
Original Bill of Lading (BOL) (must show freight class, weight, piece count, and special instructions)
Carrier Freight Invoice (itemized statement showing linehaul, fuel, and accessorial charges)
Signed Proof of Delivery (POD) / Delivery Receipt (showing delivery timestamp and any driver notations)
Rate Confirmation / Written Spot Quote (Copy of agreed contract pricing or tariff quote for this shipment)
Weight & Inspection Certificate (Scale tickets or dimensioner logs if disputing reweigh or reclass charges)
Cargo Repair / Replacement Invoices & Photos (Commercial invoice showing product value and photos if claiming physical damage)
By signing below, the claimant acknowledges and agrees to the following terms:
Authorized Representative Signature
Phase 1: Intake & Document Verification
Intake Verification: Received form, verified BOL, carrier invoice, and signed POD are attached.
System Status Check: Verified shipment status and confirmed invoice is placed on administrative hold.
Tariff & Contract Check: Cross-referenced customer contract rate matrix against billed invoice pricing.
Phase 2: Technical & Operational Audit
Terminal / GPS Telemetry Audit: Checked truck GPS logs and geofence data for detention time or missed delivery windows.
Reweigh / Density Audit: Cross-referenced scale calibration certificates against carrier certified dimensioners.
Driver / Terminal Manager Review: Interviewed origin/destination terminal dispatch regarding accessorial equipment use (e.g., liftgate, pallet jack).
Phase 3: Resolution & Final Determination
1. Audit Determination
Billing / Rating Error Identified: Linehaul or fuel surcharge error confirmed; revised invoice issued.
Accessorial Charge Disallowed: Carrier failed to provide driver notation or proof of extra service; charge removed.
Freight Claim Approved (Damage/Loss): Cargo liability confirmed; credit or payout authorized under Carmack terms.
Dispute Denied (Valid Charge): Carrier documentation (scale tickets, POD notation, GPS logs) verified charges as accurate.
2. Financial Adjustment & Action Taken
Credit Memo Issued (Applied to customer account balance)
Revised Invoice Issued: New statement sent with corrected rate/accessorials.
Formal Denial Notice Sent: Written explanation and carrier telemetry/scale logs provided to customer.
Credit Memo Amount
Auditor Notes & Summary
Auditor Signature
Form Template Insights
Please remove this form template insights section before publishing.
This template functions as a binding intake channel for shippers/consignees and a systematic audit protocol for freight billing specialists and 3PL compliance managers. Every field is engineered to eliminate back-and-forth friction and establish objective proof.
I. Shipper / Consignee Identification
Why it’s needed: Establishes account standing and contractual roles.
II. Shipment & Carrier Details
Why it’s needed: Pinpoints the exact shipment across complex carrier networks.
III. Financial Discrepancy Breakdown & Scope
Why it’s needed: Defines the exact financial exposure and protects cash flow.
Section 4: Detailed Logistics Narrative
Why it’s needed: Provides qualitative operational context.
V. Accessorial & Cargo Condition Log
Why it’s needed: Focuses directly on the primary sources of freight invoice friction.
VI. Document Checklist & Attachments
Why it’s needed: Replaces subjective arguments with legally binding evidence.
VII. Terms, Authorizations & Signatures
Why it’s needed: Establishes legal attestation and compliance terms.
VIII. Carrier & Logistics Audit Log (Internal Use)
Why it’s needed: Delivers an auditable, step-by-step resolution trail.
Mandatory Questions Recommendation
Please remove this mandatory questions recommendation section before publishing.
Here are the critical required questions for this template and the exact operational, legal, and financial reasons why logistics teams must make them mandatory:
1. Claimant Details & Filing Party Identification
2. Core Logistics & Tracking Identifiers
3. Type of Cargo Loss or Damage
4. Total Claim Amount in Contention
5. Cargo Status, Packaging Retention & Salvage Status
6. Mandatory Supporting Documentation Attachments
7. Authorized Attestation & Signature
To configure an element, select it on the form.