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GOODS-IN-TRANSIT CLAIM FORM

BRANCH POLICY NO CLAIM NO

DATE OF PAYMENT OF LAST PREMIUM
insured's name
address
date, time and place of loss or damage
date time place
date goods collected
date of delivery
destination of goods
name of carrier
nature of contract (if printed contract enclose copy)
if by rail, at whose risk were goods conveyed?
if by road, state registered letters and number of vehicle
name of the insurers of the vehicle
description of goods
value of consignment
circumstances of loss or damage
name and address of witness(es)
amount of claim
value of salvage (if any)
how were the goods packed and by whom?
how who
was the loading supervised by a senior official of your company?
yes no
condition of package when received (if claim is for pential loss)
nature of receipt given driver or consignee?
if claim for recovery made against carrier or third parties give particulars and result (correspondences should be attached to this form)
is there any other insurance covering the loss?
yes no
if so, state nature of cover and company interested
nature coy interested
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
(C) the signed delivery note obtained when the goods were delivered
(D) any other relevant documents or correspondence received

i/we declare the foregoing particulars to be true and complete and that i/we hold no other policy indemnifying me/us in respect of this claim.
do you agree
yes no
 
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