Date: 09/05/2010 Declaration No.
Name of Insured Telephone No.
Email
Address
Value of entire shipment in U.S.
Moved From Pick up Date
Delivered to Delivery Date
Packed by Unpacked by
Vessel/Air carrier Bill of lading, AWB No.
Container No. Seal No.
Were goods in storage at origin? Yes No Dates
Were goods in storage at destination? Yes No Dates
Name and address of warehouse
Was Inspection Performed? Yes No
If yes, who made inspection: Submit copy of inspection with claim Carrier Insurance Survey Agent
Date loss or damage was discovered
Were claimed items insured under any other insurance policy? Yes No

INVENTORY NO. DESCRIPTION OF ITEM AND NATURE OF DAMAGE ITEM AGE DATE OF PURCHASE ORIGINAL COST REPLACEMENT PRICE AMOUNT CLAIMED
Total amount claimed

Describe how the loss or damage occurred:

State who made estimate or appraisal:

The undersigned, signer of the foregoing statement, hereby makes a solemn oath to the statements contained herein and exhibits attached hereto, and that no material fact is withheld that should be included in this report. This also is to certify that I/we have not received any merchandise claimed short/missing from any source, to date. Should I/we receive this merchandise, from any source, I/we will promptly notify PAC GLOBAL and delete the items from the claim, or if claim has been paid, I/we will return the monies paid.