Please fill out this form as complete as possible, press “send”, and an email will be created. You can still attach documents as you normally can, when sending emails. In case you cannot attach any documents, send documents to our fax no + 31 10 4564170.

In case of a an urgent matter, we kindly request you to contact us by telephone first, so we can respond immediately and take the necessary measures.                                           

Company name Address City    Zip   Country Name Email address Phone / mobile phone Fax Insurance broker and/or insurer Insured (if other company than company name) Insured reference or file number Insurance certificate or declaration form (please attach copy) Description of goods and quantity Name of vessel or barge or warehouse or licence plate truck: B/L number or Way bill number or storage document/contract: Date of issue of document Place of loading Place (or intended place) of discharge Date of loss or date of discovery of loss Address or berth where damage occurred incl. person in charge and contact details Cargo superintendent involved, incl. name of person in charge and contact details Short description of damage (water damage, theft, heating, shortage, etc.) In case of theft, has theft been reported to local police Yes No Unknown Not applicable  If yes, send us copy of protocol or police report Estimation of loss in EUR USD Unknown   Has carrier or storekeeper been held liable in writing for the damage Yes No Unknown Not applicable  If yes, send us copy. If no, this should be done immediately Has carrier or storekeeper appointed a surveyor on their behalf   Yes No Unknown Not applicable  If yes, who was instructed + phone Value of the goods(market or invoice value) On what terms (Incoterms) where goods purchased or sold  please send us a copy Indication of cause of the damage Brief Description of Incident or Loss and Subsequent Events Remarks