\.,

STANDARD FORM FOR PRESENTATION OF LOSS AND DAMAGE CLAIM

Date: 03/11/09Claimant numb;;r;._' _

o Lossl~~::n:~clion with~ fnllowing des~:i~[d "

/ft,/'l'ld (C!.?t:tldm,) :If 3e;o7

TO: Werner Enterprises14507 Frontier RondOmaha, NE 68138

.This cla~ for $ (p()i'8. 61Cfs made: against the carrier forshipment:

(Paid.FreiSbt Bill Number) (carfI'l'llllerNlimber)

DETAILED STATEMENT SHOWING HOW AMOUNT OF CLAIM IS DETERMINED(Number and description of8J:ticles, nature and extent ofloss or damage, invoice price ofarticles, amount ofclaim" etc.)

ALL DISCOUNTS AND AllOWANCES MUST BE SHOWN

~~..... ;l.ruo.,Q'::l7. ']y.:h~O I(J)~~ ~:3

I'l,./-i ., . &(, • ~O I, '/4IiIW I 8 1':;1,.73 'E:R-r.JJ-i ." If II~. 73 el'J-(•.J,{J'" .1 IVt... 1<'1 'PO.

TIm FOLLOWING DOCUMENTS ARB INCLUDED IN SUPPORT OF TBIS CLAIM:

o Original Bill ofLading 0 Pictor.so Original Invoice or Certified Copy 0 "IhspCCtiOD ReportsoOriginal Paid Freight Bill 0 Consignee Concealed Loss or Damage

Notification Form(Note: The absence afany document called for in connection with this claim: must be explained. When impossibll!l for claimants to produce original

bill oflading orpaid freight bill, 8 bond ofindcmnitymust be given to protect carrier agninst duplicated claim supported by original documents.)

INDEMNITY AGREEMENTIn the ab5ence ofihe Original Freight Billlor Original Bill ofLading, we agree: to hold the above named carrier to whom this claim is presented andany other participating carrier, hamiless and indemnified against any and all lawful claims which may be made against it or them arising out ofthesame shipment and will pay to the said cmrier and auyparticipating carricr(s), alilosscs, danmges, costs. counsel fees or any other expenses which

they or any ofthem may sufferor pay by reason ofpayment ofour elaim. herein described, without the surrender ofthe Original Freight Bill or BillofLading, as such was not provided andlor cannot be located.

Piono.- 'Ba..-C(iL =1'c'-n±,IA~:}t>=I1'-!..:f..!-'M-"'--- _CISlI7\lt'S Printed Name CompanyName

~io.{l4~a-ee-' q(j;), NickolWl t:dClaImant's Signnturti' Company Address

97rJ. 'ti'S'';,!'''-{ I17J-J{ fI(J,,: 115'f-1r3'i1 (}zaL~ -r;/ -1571'/-2--Phone NumberlFax Number --l.--f:r-

_ -__ page2J!

________________________• • 0. _ •• • __

STANDARD FORM FOR PRESENTATION OF LOSS AND DAMAGE CLAIM

TO: Werner Enterprises14507 Frontier RoadOmaha, NE 68138

Date:Claimant number: _Carrier Number:_.,...~ _

.';l'his claim for $ is made against the carner for 0 Loss [] Damage in C cClion with the following describedshipment:

(Shippa-'s Name) (Consignee's Nlltnc)

(Consigncc: Chy, Slllle)(Sbippcr: City, State) /-l---";::::::::::::::::::;;{Bjiaihl.orii':';l<didiiittttiir"w."",;:B,B»!=:::===/::;;Z'-5..---'=====::;(iii~';;;;Jlttlil;;;oi'ir8e","Ii;;;"i;;dl;;;lg:e"";;;;';;lit;;i);====----

(DateofBm oCl.ading) ([)ute:: of'Dclivery)

(CnrfI'raUcr Number)

DETAILED STA NT SHOWING HOW AMOUNT OF CLAIM IS DETERMINED(Number aDd descripti ofBrticlcs. nature and extent of loss or damage, invoice price ofarticlcs, amount ofclaim. etc.)

All DISCOUNTS AND ALLOWANCES MUST BE SHOWN

U~1\NlA.~

TOTALAMOUNTCLAIMED I4OY3. alP

THE FOLLOWING DOCUMENTS ARE INCLUDED IN SUPPORT OF THIS CLAIM:

INDEMNITY AGREEMENTIn the absence ofthe Original Freight BilVor Original Bill ofLading, we agree to hold the above nmned carricrto whom this claim is presented andany other participating carrier. harmless and indemnified against any and all lawful claiw which may be made against it or them arising out of thesame shipment nnd will pay to the said carner and any participating carrier(s). all losses. damages, costs. counsel fees or any other expenses which

they or any ofthem may suffer or pay by reason ofpayment ofour claim. herein described, wilhout the surrender oflbe Original Freight Bm or BillofLading. as such was not provided andlor cannot be located.

o Original Bill' ofLading 0 Pictureso Original Invoice or Certified Copy 0 Inspection Reports[] Original Paid Freight Bill 0 Consignee Concealed Loss or Damage

Notification Faun(Note: The absence ofBnydocumenl called for in"connection with this claim must be explained. When impossible for claimants to produce original

bill oflarling or paid freight bill, a bond ofindcmnity must be given to protect carrier against duplicalcd claim supported by original documents.)

Claimant's Prinkd Name Company Name

Claimant's Signnturt Company Address

Phone Number/Fax Number

STANDARD FORM FOR PRESENTATION OF LOSS AND DAMAGE CLAIM

TO: Werner Enterprises14507 Frontier RoadOmaha, NE 68138

Dale:Claimanl namber:_-:::_""----Carrier Number:?'~'__ _

lbis claim for $ is made against the carrier forshipment:

(Shipper's Nnme) (Consignee's Name)

(Shipper: City, SlOte) (Consignee: CilY. SIDle)

(r1ll.mc-ofDelivering-Qnicr)-

(I>.l.te or Delivery)

(CnrlI'railcr Number)

DETAILED STATEMENT SHOWING HOW AMOUNT OF CLAIM IS DETERMINED(Number and description of lI.wcles, natllrt and extent of loss or damage, invoice price ofarticles. amount ofclaim, etc.)

.AU. DISCOUNTS AND ALLOWANCES MUST BE SHOWNtAtV--rINU~O

,'3'3/ ;).. Sel to:

1'/1";; •31J.

Q.h,7:;J5Ool<{3~. 80

"iil'ITJol V :3 ;;I. '3/~57:>O 14 -a~. '3

I57;O/CI13;;J, <f(7'iM?JOov(l~. v-J GI.;;}-SlJOo I.P. . u7 :3

TOTAL AMOUNT CLAIMED

TIlE FOLLOWING DOCUMENTS ARE INCLUDED IN SUPPORT OF mIS CLAIM:

I

o Original Bill ofLading 0 Pictures[] Original Invoice or Certified Copy 0 Inspection Reports[] Original Paid Freight Bill [] Consignee Concealed Loss or Damage

Notification Fonn(Note: The absence of any document Clllled for in corinection with this claim nmst be elI:pleined. When impossible for claimants to produce original

bID oflading or paid freight bilT, a bond ofindcmnitymust be given toprotect carrier against duplicated claim supported by original documents.)

INDEMNITY AGREEMENTIn the absence oithe OriginDl Freight BilVor Original Bill ofLading, we agree to hold the above named carrier to whom this claim is presented andany other participnting carricr.luumlcss and indcnmified against any and a111awful claims which may be made against it ar them arising aut afthcsame lihipment and wm pay to the said carrier amI'anypmticipating carricr(s), all losses. dnmages. casts, counsel fees af any ather expenses which

thcyor any afthe:nunay suffcT or pay by renson afpayme:nt afour claim, herein described, without the surrender ofthe Original Freight Bill or BillofLading, as such was notprovided and/or cannot be located.

Claimant's Printed Name Company Name

Claimnnt's Signature Company Address

Phone NumbetlFax Number

Werner Enterprises14507 Frontier RoadOmaha, NE 68138

TO:

STANDARD FORM FOR PRESENTATION OF LOSS AND DAMAGE CLAIM

Date: 03 J /110 'IClaimant number!Camer Number. -------

This claim for $, is made against the carrier for 0 Loss ~al1Ulge in connection with the following describedshipment: F

r{llil 0 ni-\1 i-hm~ D.'v-I- -tt 3q D'1(Sm"""N?v' (Co;;i~,)

fl",dMd. . ..J.A ---'2.JLUhoma. Ci.J.u. ok(Shipper: (!i~.~tllte) (Consignee: City, SItrtc)r,

ty1 t'vlon i,.J{" INex n-e..yilLotLading.Issued..B-y)........-.... ------9l.fI1lH)~lIWFins-Ganiel}-

/,otne/Cl'i lob;, Ilo)f(Dati orBilI of Lading) , (DI«c of Delivery)

1~/:t/qf)' 335?<;(paid Frcig)lI Bill Number) (CuIliuilcrNumbcr)

DETAILED STATEMENT SHOWING HOW AMOUNT OF CLAIM IS DETERMINED(Nmnbcr and description ofnrticlcs, nature and extent oiloss or damage. invoice price ofarticles, amount ofclaim. etc.)

'ALL DISCOUNTS AND ALLOWANCES MUST BE SHOWN

l1-1-.l-u h1...1 ',<; ..J.h L WVJlI nC CI"... t1:./- J..h" J ",ll.\ ;~/.APd +t> LJ..'AA/J~ot it' '.14 oCj I I

"iWril ~?fgft?: .. §~fI Fttjl 113~.':r7

TOTAL AMOUNT CLAlMED '",aq In""

THE FOLLOWING DOCUMENTS ARE INCLUDED IN SUPPORT OF THIS CLAIM:

I

1

oOriginal Bill ofI.ading 0 Pictureso Original Invoice or Certified Copy 0 Inspection Reportso Original Paid Freight Bill 0 Consignee Concealed. Loss or Damage

Notification Form(Note: The absence ofonydocument caUed for in.connection with this claim must be c:xp1ajned. When impoSSlDle for claimants to produce original

bill ofladiDg orpaid fre.i!!htbfll, a bond ofindemnity must be given 10 protect carrier against duplicated claim supported by original documents.)

INDEMNITY AGREEMENTIn the absence oflbc Original Freighl Bill/or Original Bill ofLading. we agree to hold the above named carrier to whom this claim is presented andany other participating carrier. harmless and indemnified against any and all lawful c1ll.ims which may be made against it orth~ arising aut afthcsame shipment and will pay to the said camer and lilly participating carric:r(s}. an losses, damages, costs, counsel fees or any other expenses which

they or any ofthem may suffer or pay by fCllSOn ofpllyment ofour claim, herein described. witham the SWTellder ofthe Original Freight Bill or BillofWing, as such was not provided and/or cannot be located.

l);~ IAI g (1 erAl rYla ibn! (.(."-- _Clm"clSPrinted Nam, Company Name

~QJt4)& C& q,o~ Nte.N> 18b.1 120/Claimant's Signature Company Address

qv.'f~'~'foi!r~w."v5"'l.Y3f{/ 6a/1tM\4 7)(. J:ibY1-Phone NllmbcrlFaxNurn~. •

IJ3J:12/2if09) Cargo ~I(lims - 08!!.8 001

STANDARD FORM FOR PRESENTATION OF LOSS AND DAMAGE CLAIM

Werner Enterprises14507 Frontier RoadOmaha, NE 68138

TO: Dale: oalll/O'1Claimant num~er:_" _Carrier Number: _

This claim for $ J031 . 'lOis made against the camer for 0 Loss ~nmage in connection with the following describedshipment: • {"i aJtJ;:i1rippf$;N""'J HPrn p, !2f.clm.! 510,;(

--.E.!..~/CiJ;~ DKJ~~,,(1W I D~h1. MCVI;.If WUI1.e..v"

(Bill ofLading llsued By) (NameofDcllvcring Carrier)

------~-----701-ru-!x::~:---·-------- ----------------1(j!';j;7t~;'{I1_:;------------------------

1~7f(lqrl 13Sfp3(paid Freighl Bill Number) ------==-~~(C:;,.:;"':.,"::;II;::":;:N;::.-=") ----

DETAILED STATEMENT SHOWING HOW AMOUNT OF CLAIM IS DETERMINED(Number and description ofarticles, nature and extent of loss or damage, invoice price ofarticles, amount ofclaim, etc.)

ALL DISCOUNTS AND ALLOWANCES MUST BE SHOWN

~+N. t..o'f&} Jl- c ry/ ;+- H.e) /Ala S i sslUd -h, J-h.M.£~ f!' aq O'.!;!

~ ~O/S-3a-. /3 aij ; j 'ii??ri 'FA.;J---a>O 1<:''4';1 16-5".>J- r." \. 1 J; j_S~ f17J"~

~3A. ;;1.'0::2 /9Joo ,- 530·5'3 , ~I:l-

Io;}-,/q O/eJd-O dJ. "37. ~"l' ~t:I-

~140~OW~/o/)oon,s M'·., 0.."': ~ IS7/. 00 '/,e,1!1-

TOTALAMOUNTCLAIMED 10:-<.1 VfJ

THE FOLLOWING DOCUMENTS ARE INCLUDED IN SUPPORT OF TIllS CLAIM:

o Original Bill ofLading 0 Picture.o Original Invoice or Certified Copy 0 Inspection Reportso Original Paid FreightBill 0 Consignee Concealed Loss or Damage

Notification Form(Note: The absence afany document called for in connection wiih this claim must be explained. When impossible for claimants to produce original

bill oflarling or paid freight bill. a bond ofindenmity-must be given to protect carrier against duplicated claim supported by original documents.)

INDEMNITY AGREEMENTIn the absence ofthc Origina) Freight BilVor Original Bill ofLading, we agree to hold the above named carrier to whom this claim is presented andQIlY other p.mcipating carrier. hmmIess and indcnmified against any and all lawful claims wbich may be made against it or them arisiog out oflliesame shipment and will pay to the said enrrier and any participating canier(s), all losses, damages, costs, counsel fees or any other expenses which

they or any ofthem may suffer or pay by reason ofpaymc:nt or OUT claim, herein described. without the surrender oflbe Original Freight Bill or BillofLading. as such WIlS not provideEJ, and/or cannot be IDeated.

~-;);4n4r ... gMJA., -=-.Lm'----'--'iUL;OXi.l./J"'n"'iJ-""<-....~. _Claimant's Printed Name Compmiy Name

-A.';-hb~ '(0;;>' NichQISDJ1 i2J.Clnimanl" Signatuie Company Address

q1~'f1f5.a'f()t/fi!lCM."5'I,k3Cf1 aC~' -rt J5'O</2-Phone NumberlFaxNwn~ •

1~(3/1272b09t C§rg~ Claims ~ 6B9B ()6f ."

STANDARD FORM FOR PRESENTATION OF LOSS AND DAMAGE CLAIM

TO: Werner Enterprises Date: 113/ fJ 10114507 Frontier Road Claimant number:_' _Omaha, NE 68138 Carrier Number: _

. ThisclaimforS Wf.o7. 3::'made against the camerfo[ 0 Loss ~amage inconnectionwithlhc following describedshipment: 0

Wa hlb(h ilvrY\L n,..... .,..J.. -/F8<101~ (SIti",."..,N"",,) (C(l"~

ex v'lt.rd'c;rsK; {)J4~.'Pc~.ety,· 01<'YYl.a.J1m; ±e- bJun~

(Bill of Lading wued By) (NllmcO£ Iivering Carrier)

------~ ----l7Jltrolrr'!-------------------------n ._-'- -'-"--10- :§:rv;f"---------·---------.' " J (DalcofBilIofLadins) ( tcofDclivcry)

/COl 'Y/1 81 :3.35"(,3(Paid Frei!ht Bill Number) (CndTmiler Number)

DETAILED STATEMENT SHOWING HOW AMOUNT OF CLAIM IS DETERMINED(Number and description orarticlcs, natuIc and extent ofloss or damage, invoice price ofarticles, amount ofclaim, ctc.)

ALL DISCOUNTS AND ALLOWANCES MUST BE SHOWN

~ }:}fu CAP'( of cr.d. (.j- m" <d .ro JI-o"'l.e 'Dtp+ .b:- 310/::J500 1</;5.,. S, ./-\1 t din. q</ 1e:J!1:JS7Jo .I- 3;;;' J ~ 1-<1 $ Clr. Vo ltatit9J'bD 1 ~~:;J ;;1-3 l' 118·e;S 6'1'1;!l7XJ I rw. . ;;;. </ " '7 ,1; 11'3-. '7S' &~

< Lo.~ ;)S7}lJJ ':I,:,; 8/ .!: .j. I </S-. 7S- en~

. i/SI:iD/u3:d-. '/0 til ''I 1. !'I5.:1'3 ~. 1 til 'to'D ,;It(3,..·3'it' {\l• 10 .r -1«."i?/ I F~

--i 11r'3~. ~o'7~ t;)J...j J S Ny. </(7 Je>.R-TOTAL MOUNT CLAIMED (:A2W T"yuf. 1>

THE FOllOWING DOCUMENTS ARE INCLUDED IN SUPPORT OF TIllS CLAIM:

oOriginal B'ill ofLading 0 Pictures·0 Original Invoice or~d Copy 0 Inspection Reportso Original Paid Freight Bill 0 Consignee Concealed Loss or Damage

Notification FOIIll:(Note: The absence ofany document caned for in connection with this claim must be explained. When impossible fur claimants to produce original

bill oflading or paid freight bill. a bond ofindemntty must be given to protect carrier against duplicated chum supported by original documents.)

INDEMNITY AGREEMENTIn the absence ofthe Original FreIght Billlor Original Bill ofLnding. we agree to bold the above named carrier to whom this claim is presented andany other participating carrier, harmless and indemnified against any and all lawful claims which may be made against it or them arising out ofthesame shipment and willpay to the said carrier and any participating canicr(s). all losses, damages, costs, COlUlseJ fees or any other expenses whichthey Of any ofthem may suffer orpayby reason ofpaymcnt orourclBim, herein described, without the surrender oftbc Original Freight Bill or Bill

_ ofLading. as such was not provided and/or cannot be located.

,..J)iWlI& Bo..ClA. . ,f,m:Y"'@m~,-,-;U-'--"'-- _Claimant's Printed N" Compliny Name

5nl8J{5ccA.-' qAA Nic.hol&O~'1 (!.JCJ~'S Signatulc ~ Company Address

C{7;}. '18'~':9'ioj '(I",l ~"'''fJfA-3'lf GM lo.nd 1)( JtiO'f2Phone NumberIFnx Number . r .

II3/1212009jC®"go. ~I?frris ~(i89~ 'Mr'

STANDARD FORM FOR PRESENTATION OF LOSS AND DAMAGE CLAIM

TO: Werner Enterprises14507 Frontier RoadOmaha, NE 68138

This claim for $ is made against the carrier forshipment:

(Shipper's Name)

(Shipper: City, State)

(Bill ofLading Issued By

Date:Claimant number:, _Carrier Number:, -:?_--

(Consignee's Nnmc)

(Consignee: City, Sl/lto)

(N;mc orDclivcring Carrier)

(Date of fUeling) (Date oC Delivery)

(paid Fn:ight Bill Number) (CarlTraiIcr Number)

II

DETAILED STATEMENT SHOWING HOW AMOUNT OF CLAIM IS DETERMINED(Number and description ofarticles, nature and extent afloss or damage, invoice price ofarticles. amount ofclaim. etc.)

, ALL DISCOUNTS AND ALLOWANCES MUST BE SHOWNcP I-I-n NUro

"1kfm O1!?bO;l~3(j . awl QlBI I $ d?=S' ,"ito I t"FtI I

TOTAL AMOUNT CLAIMED WID .-3.;1

TIlE FOLLOWING DOCUMENTS ARE INCLUDED IN SUPPORT OF TIllS CLAIM:

o Origimd Bill ofLading 0 Pictureso Original Invoice or Certified Copy 0 Inspection ReportsoOriginal PaidFreightBill 0 Consignee Concealed Loss or Damage

Notification Form(Note: The absence ofany document called for in connection with this claim must be explained. When impossible for claimants to produce original

bill oflading or paid freight bill, a bond ofindenmitymust be given to protect earner against duplicated claim supportt:d by original documents.)

INDEMNITY AGREEMENTIn the absence ofthe Original Freight BilVor Original Bill ofLadiDg, we agree to hold the above named canierto whom Ihis claim is pre&CIlted andanyothcrparticipaling carrier, harmless and indcnmified against any and alllawfuJ claims which maybe made against it orthcmarising out ofthesame shipment and will pay to the said carrier and any participating cmrier(s), all losses, damages, costs, counsel fees or any other expenses which

they or any ofthem may sUffer or pay by reason ofpaymcnt ofour claim, bcrcin described, without the surrender ofthe Original Freight Bill or:BiIIofWing. as 6UCh wns not provided andlor ctIJU10t be Iocmed.

j .....__.. --_._- .. Claimant's Printed Nmnc

Cloimant's Signature

Phone NumberJFax Number

CompanyName

Company Address