GOODS IN TRANSIT CLAIM FORM

STATEMENT AND PARTICULARS OF CLAIMS

The Issues of this Claim Form is in no way an admission of liability. It should be completed as fully and accurately as possible and returned immediately.

Policy No.:

Claim No.:

Insured:

Contact/Postal Address:

Occupation:

State:

Email:

Telephone/Mobile:

PARTICULARS OF LOSS OR DAMAGE

Place where damage occurred:

Date:

Time:

Date discovered:

Time discovered:

Describe fully how loss or damage occurred and circumstances under which discovered:

Destination of Goods:

Name of Carrier:

Address of Carrier:

Nature of Contract:

If Printed contract, please attach a copy:

If by rail, at whose risks were goods conveyed?

If by road, state registered letters and numbers of vehicle:

Name of insurers of the vehicle:

Value of Consignment:

How were the goods packed and by whom?

What condition were they received by carrier for transit?

Was the loading supervised by a senior official in your company?

Condition of package when received? (if claim is for partial lost):

Nature of receipt given by the carrier of the consignor. If clause, the exchange word of the clause should be stated:

Nature of receipt given by the consignee of the carrier:

Particulars of vehicle registered number:

Carrying capacity description, year of make:

Is the claimant the owner of the goods?
Yes:
No:

If not, state in what capacity the claim is being made:

The name address of owner:

If claim for recovery made against carrier or third parties give particulars and result:

Please attach correspondences here:

Is there any insurance covering the loss?
Yes:
No:

The following document(s), where applicable are required in support of this claim and should be attached to this form

(A) Invoice or account

(B) A true copy of the receipt given for the goods

(D) Any other relevant document or correspondence received

DECLARATION:

I/We declare that the foregoing answers are true and complete.

Signature

Date