Verify Shipping Insurance Claim - shopify

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Verify Shipping Insurance Claim
Please complete the form below.

A shipping insurance claim has been submitted for tracking number #420392119300110597203651927802. In order to continue processing this claim, we need the recipient, or intended recipient, to verify this is valid claim by completing the form below. Once complete, please click the "Submit Claim Verification" button.

Alternatively, you can print out and manually submit our Claim Statement/Affidavit form.

* Denotes Required Fields

Shipment Information for Tracking Number: 420392119300110597203651927802

Reference #:

747823271

What Happened to the Package?:*

If Damaged, Is/Are the Item(s) Repairable?:*

Requested Resolution?:*

Recipient / Buyer / Consignee Legal Statement

To be signed by the recipient (damaged packages) or intended recipient (lost packages)

I certify that the information above is correct and truthful. I understand the consequences of fraud as described below.

Warning: Any fraudulent claims will make the shipper and/or consignee liable for any prosecution for mail fraud under federal crime code. 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).

Full Name of the(Intended) Recipient:*

Todays Date:*

Your IP Address:

172.71.254.2

Your IP Location:

United States of America - Illinois

Original Package Shipped To:

MS US