Claim Form
For Lost or Damaged USPS Parcels and Fed-Ex Domestic shipments

Instructions
1. Fill out the claim form completely, attach all paperwork and mail within 90 days from the date of shipment.
2. For lost parcels, you must wait 14 days domestic and 45 days for international and APO/FPO shipments. The signed letter from the consignee (recipient) must also adhere to these guidelines.
3. Staple to this form the following pieces of information:
A. A copy of the original invoice to the consignee.
B. A signed and dated letter from the consignee stating the following:
1) Invoice or auction number.
2) Description of product.
3) If loss, state parcel never received; if damage, state description of damage and if repairable.
4) Signature and date.
C. If the claim is for damage, hold on to the damaged item until the claim is resolved as pictures may be requested.
4. Freight charges are only recoverable if the freight value is declared in the insured value.
5. Mail to:     U-PIC                                                               Fax to:  818-971-3325
       28001 Dorothy Dr., 2nd Floor         or
       Agoura Hills, CA 91301
6. If you have any questions, please call our office at 800-955-4623, option 4 for claims.
 
Claim Information:


Company:       [______GSCM____________]

 

 

Name              [_______________________]
Address:          [_______________________]
Phone:             [_______________________]

 

Email:                [_______________]                                                  

 

Carrier:            [_______________________]

Invoice #:         [_______________]

Consignee:       [______________________]

Consignee Zip/Country:     [________________]

 

Ship Date:        [______________]

Tracking #:       [______________________]

Declared Value: [$_____________]

Claim is for: Loss: ___ Damage: ___ Shortage: ___     If Damaged is it repairable? Y / N

Description of Items:              ________________________________________________

Description of Damage:         ________________________________________________

Amount of your claim  

Invoice Value:

$________________

Total Claim Amount:

$________________

Less Amount Recovered (if damaged):

$________________

Balance To Be Paid By Underwriters

$________________

Claims checks should be mailed to the attention of:    _________________________________

Prompt settlement of your claim will be subject to the full completion of the above claims information and submittal of the required documents. Failure to comply will delay settlement.

Signature:    _____________________________________   Date:    __________________________
 
WARNING: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. (CC1871.2)