Cargo/Freight Insurance Claim form

Please fill out the following form, print and FAX along with the other required claim documents to 805-267-4832.
Please give answers to all questions, where possible. The carrier or shipping agent should be able to supply information if necessary.

 1) Certificate #:   (Located at the top of the Policy,  IE: # 1043251856)

        Coverage Type: All Risk or   Basic Coverage ?

 2) Name of Loss Payable as listed on Certificate:     Shipment Date: 

 3) Name of Carrier: Method of Transport:Land  Air  Ocean (Check)

 4) Details of Transit                                                                                                                                               

  Shipment FROM: City: State: Country:

  Shipment TO:       City: State: Country:

 5) Delivery Date:    Delivery Address:

 6) How was the shipment transported from the above address: Please Check

     From a lorry/van?   From a returnable Container?   Other:

 7) Please state the Name and Address of the agent who arranged clearance and delivery of  your goods:  

 8) Was the loss or damage of the goods noted on delivery:  Please check:  Yes   No

 9) Was the shipment observed to be damaged at the time of delivery: Yes  No

 10) Did you report the loss or damage to the carrier at the time of delivery:  Yes  No

 Please Note: A written claim must be made to the Carrier, for any loss or damage
 noticed on delivery, and the Carrier's reply must be enclosed with your claim.
 Should some of your goods be missing on delivery and there is no evidence
 of pilferage during transit, please contact the carrier and the delivery agent, 
 as the goods may still be at their premises and can be forwarded to you.

  Did the following occur during the transport of your shipment with the carrier:

 A) Collision of truck or carrying conveyance:  YES   NO

  B) Overturning of truck or carrying conveyance: YES   NO

  C) Fire: YES   NO

  D) Theft of the ENTIRE shipment:  YES   NO

  E) Theft of a portion of the shipment: YES   NO

  F) Non delivery of the ENTIRE shipment:  YES   NO

  G) Non delivery of a portion of the shipment: YES   NO

  H) Act of Nature (Earthquake, hurricane, storm etc):  YES   NO

  I) Carrier dropping items while loading or unloading items:  YES   NO

  11) In your opinion, what was the cause of the loss or damage to your shipment: 

12) In your opinion, do the damaged goods retain any salvage value: Yes No                 

         If yes, please give details:

13) Is there any other Insurance coverage for this shipment, which may contribute to the loss:

Yes No  If Yes, please give details of the Insurance Company and the policy number:

Statement of Claim and Declaration

Please give  the number of items Lost or Damaged, as well as, a full description, Nature of claims, Invoice Value of each item

Description of Item(S):

Nature of Claims:

 Invoice Value of each item:        

 Total $ Amount you are claiming damaged/lost (Or cost of repairs):  

Declaration Statement:    I/We hereby declare that the whole of the statements made in this form, in respect to loss or damage as claimed above, which occurred during transit to the address listed above are true in every respect; and I/We agree that if I/We have knowingly made any false or untrue statements or concealed any material facts, Our/My right to recover under the Insurance conditions shall be absolutely forfeited.

Claimants Name:

Claimants Address:

Authorized Signature: Date:

Please Print this form and fax to (805) 267-4832 with the required claim documents.

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