Executive Insurance Services, Inc.

30 Windsormere Way, Suite 300 • Oviedo, FL 32765
(407) 366-2774 • (800) 801-6421 • Fax (407) 366-4604
e-mail: customerservice@execinsurance.net
CLAIM FORM for CERTIFICATE #
Name of Insured/
CLAIMANT: PHONE NUMBER: FAX NUMBER: EMAIL:

MAILING ADDRESS: PICK UP DATE: DELIVERY DATE:

                                     PICK UP ADDRESS:

DELIVERY ADDRESS: WERE GOODS STORED? Yes / No LOCATION:

DATE INTO STORAGE: DATE OUT OF STORAGE: PACKED BY: UNPACKED BY:

CARRIER NAME AND REFERENCE #: VALUE OF ENTIRE SHIPMENT $

PROVIDE NAME AND POLICY # OF OTHER INSURANCE: PREFERRED WAY OF CONTACT:

Inventory
#
Item Description
(Full Details)
Damage / Missing
(Full Details)
Purchase
Date
Original
Cost
Cost To
Replace
Claimed Amount
(Specify Currency)

* If necessary, click the Add Additional Items button below.




I am the owner of the property described above and I hereby make a solemn oath to the truth of the information contained herein and attached hereto. I certify that this submission constitutes my entire claim under this Certificate. No material information has been withheld. Further, I guarantee I will promptly notify Executive Insurance Services, Inc., if any of the missing items are received so they might be deleted from this claim, or if the claim has been paid, I will return the money paid therefore.I hereby assign and transfer to Executive Insurance Services, Inc., all claims and recoveries arising out of the shipment of my property insured under this Certificate. Further, I authorize any company involved in the movement of my property to release to Executive Insurance Services, Inc., any documents and information as may concern this claim. By submitting this claim, I certify that everything contained herin is true to the best of my knowledge.

       



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