(print on company letterhead)

Claim Ref:
Date:

To: (name of insurance company)

Dear Sir,
CLAIM STATEMENT

We regret to inform you that the following goods have been found in a damage
condition as stated below:

Insured / Claimant :

Transit :

Description of goods :

Under Invoice No. :

Claim Amount : (Details of claim breakdown)

We will be highly appreciated to see your kind remittance to the bank account as
follows:

Beneficiary :

Account No. :

Bank :

Bank’s Address :

Thank you for your cooperation.

Sincerely,
(Your name, signature and office seal)
Tel: Fax: Person in charge:
Address: