Baggagexs RP No.
Full Name: Date your goods were shipped?
Address: Date goods were delivered to your residence?
Where and when did you discover your loss?
Phone Residence: To whom did you first notify your loss?
*NOTE: PLEASE STATE THE CURRENCY □USD □RMB □HKD □EUR □OTHER _________
Please tick relevant column
Category on Description of item No on Missing Broken Chipped Other Purchase Replacement Insured Amount Claimed
Application Packing Scratched (Please specify) Price Cost Value
Total Amount Claimed
In order to prevent possible delays with your claim the
following items should be forwarded with this claim form:
Written professional estimates for repair or replacement REIMBURSEMENT will be made by cheque or bank transfer to the address
given above or:
Captioned photographs of damaged items with general
and close-up views
CORRESPONDENCE TO: Bank Name
Marine Adjustors Ltd Bank Address
Suite E-12-06, Block E
Plaza Mont’ Kiara
No.2, Jalan Kiara, Plaza Mont’ Kiara
50480 Kuala Lumpur, Malaysia
TEL : +60 3 6201 6163 Bank Account No
FAX : +60 3 6201 5962
Email Address : firstname.lastname@example.org Bank Swift/Sort Code
Name of Account Holder
I certify that the claim presented is correct and truthful and that no material information has been omitted. I am only claiming for items lost/damaged during the
NB : The above information is to be submitted within 14 days of date of claim notification and in any event, no later than 30 days by fax or email.
Any requirement for an extension of time may be considered upon a request in writing stating the reason(s) for such extension .