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Small Parcel/Cargo Insurance: Claim Information Sheet

This document is a claim information sheet for lost, stolen, or damaged parcels. It collects information about the buyer/recipient making the claim such as contact details and a description of the claim. It also collects seller information and requires the buyer's signature certifying the accuracy of the information provided under penalty of perjury.

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Owen Ohuimumwen
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165 views1 page

Small Parcel/Cargo Insurance: Claim Information Sheet

This document is a claim information sheet for lost, stolen, or damaged parcels. It collects information about the buyer/recipient making the claim such as contact details and a description of the claim. It also collects seller information and requires the buyer's signature certifying the accuracy of the information provided under penalty of perjury.

Uploaded by

Owen Ohuimumwen
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

Small

Parcel/Cargo Insurance Buyer/Recipient Affidavit



Claim Number:______________
For Lost, Stolen or Damaged Parcels
Claim Information Sheet

Buyers / Recipients Name:_______________________________________________________________

Street Address / PO Box ______________________________________City________________________

State/Province_____________________Postal/Zip Code___________Country_____________________

Phone:______________________________Email_____________________________________________

Claim Detail
Lost / Damage / Incomplete______________________________________________________________

If Item is damaged, please describe and attach picture of damage:_______________________________

_____________________________________________________________________________________

Describe condition of package:____________________________________________________________

_____________________________________________________________________________________

Seller Information

Name:________________________________________________________________________________

Phone:__________________________________Email_________________________________________

I hereby certify that all information on this form is accurate and truthful under Federal Law and under
penalty of perjury, under the laws of the state of California. The submission of a false, fictitious or
fraudulent statement may result in imprisonment of up to 5 years and a fine of up to $10,000 ( 18 USC
1001 ). In addition, a civil penalty of up to $5,000, and an assessment of twice the amount falsely
claimed may be imposed ( 31 USC 3802 ).

Buyer / Recipient Signature:_______________________________________Date:___________________

Warning: Any fraudulent claims will make the shipper and/or consignee liable for any prosecution for
mail fraud under the federal crime code.

Should the insured and/or shipper submit a false, fictitious or fraudulent statement, it will result in the
claims being denied.

InsureShip 3211 Cahuenga Blvd. West Suite 200, Los Angeles, CA 90068
Phone: (866) 701-3654 / (818) 303-9255 Fax: (877) 859-5858 Email: claims@[Link]

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