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: [email protected]

For Lost, Stolen or Damaged Parcels Claim Information Sheet · Small Parcel/Cargo Insurance Buyer/Recipient Affidavit ... , Stolen or Damaged Parcels Claim Information Sheet ... ,

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Page 1: For Lost, Stolen or Damaged Parcels Claim Information Sheet · Small Parcel/Cargo Insurance Buyer/Recipient Affidavit ... , Stolen or Damaged Parcels Claim Information Sheet ... ,

SmallParcel/CargoInsuranceBuyer/RecipientAffidavit ClaimNumber:______________

ForLost,StolenorDamagedParcelsClaimInformationSheetBuyers/RecipientsName:_______________________________________________________________StreetAddress/POBox______________________________________City________________________State/Province_____________________Postal/ZipCode___________Country_____________________Phone:______________________________Email_____________________________________________ClaimDetailLost/Damage/Incomplete______________________________________________________________IfItemisdamaged,pleasedescribeandattachpictureofdamage:____________________________________________________________________________________________________________________ Describeconditionofpackage:_________________________________________________________________________________________________________________________________________________SellerInformationName:________________________________________________________________________________Phone:__________________________________Email_________________________________________IherebycertifythatallinformationonthisformisaccurateandtruthfulunderFederalLawandunderpenaltyofperjury,underthelawsofthestateofCalifornia.Thesubmissionofafalse,fictitiousorfraudulentstatementmayresultinimprisonmentofupto5yearsandafineofupto$10,000(18USC1001).Inaddition,acivilpenaltyofupto$5,000,andanassessmentoftwicetheamountfalselyclaimedmaybeimposed(31USC3802).Buyer/RecipientSignature:_______________________________________Date:___________________Warning:Anyfraudulentclaimswillmaketheshipperand/orconsigneeliableforanyprosecutionformailfraudunderthefederalcrimecode.

Shouldtheinsuredand/orshippersubmitafalse,fictitiousorfraudulentstatement,itwillresultintheclaimsbeingdenied.

InsureShip 3211CahuengaBlvd.WestSuite200,LosAngeles,CA90068Phone:(866)701-3654/(818)303-9255Fax:(877)859-5858Email:[email protected]