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U-PIC Insurance Services Affidavit
For Lost or Damaged Parcels

CLAIM INFORMATION SHEET

Order Number: *

Name: *

Street Address / P.O. Box: *

City: *

State / Province: *

Zip Code *

Phone: *

Contact:

E-Mail *

CLAIM DETAIL

Lost / Damage / Incomplete:

If item is damaged, please describe and attach picture of damage:

Describe condition of package:

I hereby certify that all information on this form is accurate and truthful. The submission of a false, fictitious or fraudulent statement may result in imprisonment of up to 5 years and a fine of up to $10,000.00 (18 USC 1001). In addition, a civil penalty of up to $5,000.00, and an assessment of twice the amount falsely claimed may be imposed (31 USC 3802).

Signature: *

Date: *

Those customers filing more than one claim may experience a delay in payment due to an increase in investigative time.

WARNING: ANY FRAUDULENT CLAIMS WILL MAKE THE SHIPPER AND/OR CONSIGNEE LIABLE FOR ANY PROSECUTION FOR MAIL FRAUD UNDER FEDERAL CRIME CODE.

Re-send or refund policy:
Please check one only for resend or refund

1. Resend

All order under $10.00 will refund only.

2. Refund

U-PIC Insurance Services
18961 E. Arenth Ave. City of Industry, CA 91748 Phone: 626-912-0668
Email: order@meritline.com