* CERTIFICATE #:                 * DATE:

* CLAIMANT:

* CURRENT ADDRESS:

* E-MAIL: * HOME PHONE:

 CELL PHONE: * VALUE OF ENTIRE SHIPMENT:

* DATE LOSS/DAMAGE WAS DISCOVERED:

* ORIGIN: * DESTINATION:

* DATE OF PICK UP:   * DELIVERY DATE:

* WERE GOODS STORED IN TRANSIT? YES  NO    

 DATE INTO STORAGE:  DATE OUT OF STORAGE: 

 NAME AND ADDRESS OF WAREHOUSE:

* WERE THESE ITEMS INSURED UNDER ANY OTHER POLICY/INSURANCE? YES NO

* SHIPMENT PACKED BY:

* SHIPMENT UNPACKED BY:

 *Required Field