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| STATEMENT OF CLAIM |
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NAME
ADDRESS
CITY, STATE
& ZIP |
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ORIGIN CITY & STATE |
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| DATE SHIPMENT LOADED |
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| DATE SHIPMENT DELIVERED |
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| REF. NO. |
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CLICK HERE FOR INSTRUCTIONS
PLEASE COMPLETE ALL INFORMATION BELOW AND PRESS SUBMIT |
FOR
ADJUSTER'S
USE ONLY |
INVEN-
TORY
ITEM
NO. |
ARTICLE
DESCRIBE IN DETAIL |
NATURE OF CLAIM
IF DAMAGE, DESCRIBE EXTENT |
APPROX
WEIGHT |
PURCHASED
MO - YR |
COST |
AMOUNT
CLAIMED |
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Limit 30 Characters |
Limit 250 Characters: left
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$
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| If you have more items to claim, please enter the number of additional items here: |
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| It is understood that losses from an Interstate shipment may be reported to the F.B.I. which has investigative jurisdiction under Federal Law regarding Interstate or Foreign Commerce. |
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TOTAL |
$ |
R |
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By checking here I acknowledge that I am the owner of the property described. I did not cause or contribute to the damage set forth herein. All statements made in this statement of claim and any forwarded documents are true and correct to the best of my knowledge and belief, and constitute my complete and entire claim. No material information has been withheld. |
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| CLAIM FORM SUBMITTED BY: |
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HOME PHONE NO. |
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| EMAIL ADDRESS: |
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BUSINESS PHONE NO. |
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In California, the following provision applies to your claim and may apply in other states. "For your protection California law requires the following to appear on this form.
§556. It is unlawful to:
(a) Present or cause to be presented any false or fraudulent claim for the payment of a loss under a contract of insurance.
(b) Prepare, make or subscribe in writing, with intent to present or use the same, or to allow it to be presented or used in support of any such claim.
Every person who violates any provision of this section is punishable by imprisonment in the State prison not exceeding three years, or by fine not exceeding $1,000, or by both." |
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