Customer Cargo Claim Form – Fill Out and Use This PDF

Date filed:			Claim Payable to:
UPS Bill of Lading/Air Waybill No:			Company Name
UPS Bill of Lading/Air Waybill date:			Address
UPS Order No.:		Date:	City/Town & State & Country	Zip / Postal Code
Claimant Reference No.:		Confirmation Number :
Shipper			Consignee
Address			Address
City/Town & State & Country	Zip / Postal Code		City/Town & State & Country	Zip / Postal Code

CLAIM MUST BE SUPPORTED BY A DETAILED STATEMENT SHOWING HOW THE AMOUNT WAS DETERMINED. INCLUDE A COMPLETE DESCRIPTION OF LOST ITEMS; SIZE, COLOR, MARKINGS, ETC. (If more room is needed in this section, use an additional claim form to be included with the submission of this claim form.)

Detailed Merchandise Description				Quantity	Merchandise		Total Merchandise	Weight per	Total Weight of
					Cost Each Unit		Cost	Unit (kg or lb)	Merchandise (kg or lb)
Total of Claimed Merchandise
Any additional claimed amount								Specify Reason
TOTAL OF CLAIM				Currency
Package type:	Cartons	Pallets	Crates Other:				Goods packed by: Shipper		UPS
Was the merchandise: New		Used
Do you have your own Marine/Cargo Insurance Coverage?						Yes	No If yes, list name of Insurance Carrier:
Did you purchase Cargo Insurance through SCS (AIG policy)?						Yes	No If yes, give insured value amount:
Did you purchase Declared Value with UPS?						Yes	No If yes, give declared value amount:

NOTE: Claim should be supported by following documents. Failure to include sufficient documentation may be grounds for denial of your claim and may delay conclusion of the claim. UPS reserves the right to request any additional documents not listed below.

UPS Bill of Lading/Air Waybill referenced above

Commercial invoice(s) for entire shipment showing the cost of the goods being sold by Claimant to end Consignee Packing list for entire shipment with the weight of each individual item in the claimed shipment

Signed Proof of Delivery (POD) from Consignee if applicable, or other delivery document Survey/Inspection report if survey/inspection held

Pictures of damaged product if available Repair estimate, if available

Shippers’ letter of Instruction (SLI) and correspondence pertaining to the shipment Certificate of Insurance, if shipment was insured and a certificate was issued

Other documents to support claim:

Remarks:

The statements contained in this claim form are hereby certified as true and correct.

Claimant’s Company Name:	Tel No.:
Claimant’s Contact Name (print):	E-Mail:
Claimant’s Signature:	Date:	Fax No:

Mail Claim to: UPS Supply Chain Solutions, UPS SCS Cargo Claims, 9/F, 100 Texaco Road, Tsuen Wan, N.T., Hong Kong Phone: 852-2942 5174, Fax: 852-2942 5770, Email: UPSAPACclaims@UPS.com

GIS form 0409 APEPage 1 of 2UPS Customer cargo claim Issue:005 Apr/ 01/2009

All services are subject to applicable Terms & Conditions of service, which appear in the shipping documents pertaining to your shipment. Said Terms & Conditions include, but are not limited to, liability limitations and claim filing requirements.