Presentation of Loss/Damage Claim
Please read the instructions before preparing and submitting this
form to I.T.I. It is important that the claim form be filled out completely.
*Reference#
*Date:
*Assured:
*Address:
*City:
*State or
*
Country:
Zip:
*
Email:
*Home Phone:
-
-
Work Phone:
-
-
*Value of Entire Shipment:
*Moved
From:
Date of
Pickup
*Delivered
To:
Date of
Delivery
*Were Goods in Storage?
Yes
No
Dates
Name and Address of Warehouse:
*Were these items insured under any other policy or insurance coverage?
Yes
No
*Packed By
:
*Unpacked By:
Inv. No.
Item
Nature of Damage
Item Age
Date
Acquired
Original
Cost
Replacement
Cost
Amount
Claimed