Claims Request Form

Please complete all fields in order to have your claim processed in a timely manner. (Use the TAB key to move through the form.)
Please include a color photograph(s) which clearly show(s) the defect and the container label.
Questions: Call Matt Bianchi at 209-826-9494 x 108 or email mattb@ingomar.com
Ingomar will review your request and advise you of the status of your claim via a “Claim Status Summary” acknowledgement. Until receipt of an approved “Claim Status Summary” acknowledgement, claim(s) will be considered pending and not valid.

Claim Information

Date of Claim:
Contact Person:	required
Contact Email	required
BOL Number (s):
Product:
Product Code:
Company Name:	required
Customer Claim No:
Contact Number:	required
Container Lot Number (s):
Photos Maximum size is 5mbs combined. Attach Photo Attach Photo Attach Photo Attach Photo Attach Photo
Description of defect:

Total lbs of claim:
Product Cost (price per lb, must equal Ingomar’s invoiced price)	$
Total Product Cost = (Total lbs x Product Cost)	$
Freight Charges: (if applicable)	$
Disposal Charges (if applicable):	$
Bin Charges (if approved):	$
Other Charges:	$
Total Claim Requested:	$