Claim Form

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Inventory Item #Article (Describe in Detail)Nature of Claim (If Damage, Describe Extent)Approx. WeightPurchased Mo - Yr.CostAmount Claimed 
  • It is understood that losses from an interstate shipment may be reported to the F.B.I. which has investigative jurisdiction under Federal Laws regarding interstate or Foreign Commerce.
  • I am the owner of the property described. I did not cause or contribute to the damage set forth herein.
  • Date Format: MM slash DD slash YYYY