| CLAIMS
NOTIFICATION: |
| *Assured's Name: |
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| *Claimant's Name: |
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| *Date of Sailing: |
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| *Certificate Number: |
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| *Date of Shipment: |
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*Forwarder's/
Shipper's Name: |
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*Type of Commodity
insured: |
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| *Nature of Damage: |
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| *Amount of Damage: |
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| CONTACT
INFORMATION: |
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| *Contact Name: |
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| *Contact Phone Number: |
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| *Contact Phone Number: |
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| *Do you have the original insurance certificate? |
Yes
No
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| *Do you have all supporting documents? |
Yes
No
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| Please
refer to insurance certificate/procedure of
claims form. |
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Please note claims will not
be processed or delayed if all supporting
documents are not provided. Please send
all documents to our office at:
142 Mineola Avenue Suite 3D
Roslyn Heights , NY 11577
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| * Fields
Are Required |
