Claim Form For Lost Or Damaged Packages printable pdf download

CLAIM FORM

Use this form for lost or damaged packages.

Claims can also be filed online at

Revised 5/2016 – Updated Logo to Reflect An Assurant Company

INSTRUCTIONS:

1. File a tracer with the carrier for lost shipments and notify the carrier about damaged packages as soon as possible.

a. Take proper exceptions on the delivery receipt when any loss or damage is apparent at the time of taking delivery.

2. Complete a SHIPSURANCE claim form, and provide all required documents within one hundred and twenty (120) calendar days from

the date of shipment.

a. If the shipment is sent via the United States Postal Service (USPS) or USPS consolidators and the claim is for loss, the Insured must

wait 20 calendar days (Domestic shipments) or 40 calendar days (International shipments) before filing claim with SHIPSURANCE.

3. Attach the following to this form:

a. Copy of the carrier's tracer/claim form with the claim number, tracking number, and other related information from the carrier.

b. Copy of the carrier's settlement check and stub. DO NOT WAIT FOR CARRIER CHECK TO FILE CLAIM WITH SHIPSURANCE.

c. Copy of original invoice/receipt to/from the recipient.

If the claim is for damage please describe the damage. If repairs are possible, include the cost of the repair from disinterested

party. If repairs are NOT possible, include the salvage value.

ii.

If the claim is for damage, photos and inspection may be required. Retain all packaging material and damaged goods in its

original form as received. DO NOT FAX PHOTOGRAPHS.

d. Shipments sent via the United States Postal Service (USPS) or consolidators: Claim statement/affidavit form signed by the recipient.

4. Copy of the monthly insurance report reflecting insured value, either computerized or by hand.

818-668-8899

5. Mail: SHIPSURANCE, 21900 Burbank Blvd., Ste 100, Woodland Hills, CA 91367 • Fax:

• Email:

Policy/Certificate Number: __________________________

Today’s Date: __________________

Insured’s Name: __________________________________________________________________________________________

Address Shipped From: ____________________________________________________________________________________

FAILURE OF THE INSURED OR THE RECIPIENT TO RETAIN DAMAGED PROPERTY AND PACKAGING AS RECEIVED

COULD AFFECT FINAL SETTLEMENT OF THE CLAIM.

Recipient’s Name: ___________________________________

Recipient’s Phone: _____________________

Recipient’s Address: ______________________________________________________________________________________

Carrier: ______________________

Tracking #: ________________________

Carrier's Claim #: ______________________

Shipment Pickup Date: __________ Date Loss Discovered: _______________

Invoice #: ____________________________

Description of Item(s) and Damage: __________________________________________________________________________

______________________________________________________________________________________________________

AMOUNT OF

CLAIM

Claim Type: Loss ___ Damage ___

Invoice or repair cost of items lost or damaged:

$ _______________

Shortage___

(Amount cannot exceed value declared upon shipment)

Less amount paid by carrier:

$ (______________)

Repairable?: Yes ____ No ____

Less salvage value of damaged goods:

$ (______________)

Balance To Be Paid By Underwriters:

$ ____________

I certify that the above statements are correct.

Signature: _______________________________________ Telephone: ____________________________

Fax: ____________________________ Email Address: ___________________________

Make Check Payable to: ___________________________________________________________

Warning: Any fraudulent claims will make the shipper and/or recipient liable for prosecution for mail fraud under the Federal Criminal

Code.

Shipsurance Insurance Services • CDI Number 0E39065

21900 Burbank Blvd. • Suite 100 • Woodland Hills, CA 91367

Tel 1-866-852-9956 • Claim Fax 818-668-8899

Claim Form For Lost Or Damaged Packages

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