Gis Form 0409 Ae - Ups-Scs Customer Cargo Claim Form
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1
2UPS-SCS Customer Cargo Claim Form
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Claim Amount (specify currency):
Is hereby filed for (check one):
Non delivery
Shortage
Damage
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 Cargo Claims Department,12380 Morris Road 5th Floor, Alpharetta, GA, USA 30005.
Phone No.: 866-746-2404/ 678-746-7750 Fax No.: 800-379-9084/ 678-746-7768 Email:
GIS form 0409 AE
Page 1 of 2
UPS Customer cargo claim Issue:005 Apr/ 1/2009
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.
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