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POLICY #15735 US POSTAL SERVICE (USPS) CLAIM FORM For Lost or Damaged Packages ‐ Revised 02/15A INSTRUCTIONS: Send this claim form PLUS items 2 & 3. 1. Complete and sign this claim form. Your signature is required for processing. Mail: Parcel Insurance Plan 2. Attach a copy of your Amazon.com order details for this transaction. PO Box 66708 3. Attach a copy of the email from the package recipient advising you of the loss or damage. St. Louis MO 63166‐6708 4. Submit this claim form WITH ITEMS 2 & 3 above using the information to the right. Fax: 314‐692‐7598 Email: [email protected] Important Notes: 1. You must wait 30 days after the shipment date to submit a claim for a LOST package. Claims for DAMAGED packages can be submitted at any time. All claims must be submitted within 90 days of the shipment date. 2. The package recipient should hold damaged items in the event they are requested during claims processing. FAILURE TO RETAIN DAMAGED PROPERTY COULD AFFECT FINAL SETTLEMENT OF THE CLAIM. 3. If you used Priority Mail®, Priority Mail Express™, or Priority Mail Express International™, the USPS may provide automatic insurance coverage. If applicable, only the amount above the USPS coverage is insured with PIP. You are responsible for collecting the automatic coverage from USPS. 4. Warning: Any fraudulent claims will make the shipper and/or package recipient liable for prosecution for mail fraud under the Federal Criminal Code. 5. Call PIP directly with questions or if PIP has not responded to your claim within 3 weeks of filing at 800‐325‐7390 (ext 311). CLAIM INFORMATION Package Recipient’s Name: ____________________________________________ Shipment Date:_________________ Tracking or Insurance ID #:________________________________________________ Number of Packages: [ ] LOST [ ] DAMAGED [ ] SHORTAGE Description of Items: _____________________________________________________________________________ $ Amount of claim (Amazon.com sale price excluding shipping fees) $ Less amount paid by USPS, if any $ Less salvage value of DAMAGED goods (this does not apply if package is LOST) $ Balance to be paid by PIP Shipper’s Contact Information Shipper’s Name: ________________________________ Make check payable to: ________________________________ Shipper’s Mailing Address: __________________________________________________________________________ City, State, Zip: ________________________________________________ Telephone: ________________________ Email Address: ____________________________________________________ FOR PIP USE ONLY I certify that the above statements are correct. AMOUNT: $_______________________ Signature _________________________________________ DATE: _________ BY:_____________ .

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