Drop Ship Claim Request Form

Complete this form to submit a Claims Request to The Gerson Companies for Credit or Replacement. This form should only be used for Drop Ship Claims Requests.

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* 1. Please Provide Contact Information for Requester:

Requester's Name:

Business Name:

Business Account Number:

Business Email:

Business Contact Phone:

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* 2. Please Confirm Claim Request Type:

Credit

Replacement

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* 3. Please Provide One of the Following for Claim Request:
PO Number, Invoice Number or Shipment Number

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* 4. Please Clarify the Information Provided in Question #3:

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* 5. Please Provide Item Details for Claim Request:

Gerson Item Number:

Item Description:

Quantity:

Unit of Measure (Sell Pack):

Unit Cost:

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* 6. For Claim Requests with More Than One Item from the Same PO/Shipment
Provide All Additional Item(s) Information Here (Reference Question #5):

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* 7. Please Provide Ship To Location (Replacements Only):

Contact Name:

Address:

Address (Line 2):

City:

State:

Zip Code:

Contact Email:

Contact Phone:

Question Title

* 1. Please Provide Contact Information for Requester:

Question Title

* 2. Please Confirm Claim Request Type:

Question Title

* 3. Please Provide One of the Following for Claim Request:PO Number, Invoice Number or Shipment Number

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* 4. Please Clarify the Information Provided in Question #3:

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* 5. Please Provide Item Details for Claim Request:

Question Title

* 6. For Claim Requests with More Than One Item from the Same PO/ShipmentProvide All Additional Item(s) Information Here (Reference Question #5):

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* 7. Please Provide Ship To Location (Replacements Only):

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* 8. Additional Comments Regarding Claim Request:

* 3. Please Provide One of the Following for Claim Request:
PO Number, Invoice Number or Shipment Number

* 6. For Claim Requests with More Than One Item from the Same PO/Shipment
Provide All Additional Item(s) Information Here (Reference Question #5):