FOR PARCEL INSURANCE PLAN POLICYHOLDERS USE ONLY

CLAIM FORM

For Lost or Damaged Packages

(Use for package carriers other than US Postal Service)

INSTRUCTIONS

File a tracer or notify the carrier immediately if package is lost or damaged.
Complete and submit this claim form within 60 DAYS of receipt of carrier's claim payment.

Claim Form Information

Insured's Name*

Address Shipped From*

Policy Number*

Carrier*

Claim Type*

Loss Damage Shortage

Date Mailed*

Number of Packages*

You or Consignee should hold damaged items in the event they are requested during claim processing.

FAILURE TO RETAIN DAMAGED PROPERTY COULD AFFECT FINAL SETTLEMENT OF THE CLAIM.

Consignee*

Invoice Number

Carrier's Claim Number

Description of Items*

Amount of Claim: Invoice or Repair cost of contents lost or damaged, excluding shipping fees*: (Amount cannot exceed value declared upon shipment)

Less amount paid by carrier, excluding shipping fees*: (Shipping fees should be recovered from the carrier)

Less salvage value of damaged goods*:

Balance to be paid by PIP*:

Send claim check to the attention of*:

Upload a copy of carrier’s claim form with claim number.

Upload a copy of carrier's claim check and stub.*

Upload a copy of the original invoice to consignee.*

Upload a copy of repair receipt, if applicable.

Upload a copy of shipping system daily report detailing value of package insured with PIP.

Attachment format can be .jpg, .gif, .png, or .pdf files.

Signature

Prompt settlement of your claim will be subject to providing all required information requested  on this claim form and any other documentation that is requested to substantiate loss.  Failure to comply will delay settlement.
Warning:  Any fraudulent claims will make the shipper and/or consignee liable for prosecution for mail fraud under the Federal Criminal Code.

By selecting this checkbox and entering my name, I certify that the above statements are correct.*

Type your full name here *

Telephone*

Telephone Ext

Fax Number

Email*

If we have not responded to your claim within 3 weeks of filing, you may check the status of your claim at www.pipinsure.com.

* required field