NOTIFICATION OF SII CLAIM

DATE : DHL DIVISION : SII POLICY NO :

CLAIMANT'S NAME :
CLAIMANT'S ADDRESS :

IDENTITY OF CLAIMANT : CLAIMANT'S ACCT NO (if applicable) :

IF OTHER, SPECIFY IDENTITY AND RIGHT TO CLAIM :
CLAIMANT'S TEL NO : FAX NO :
CLAIMANT'S EMAIL :

SHIPMENT DETAILS
HOUSE W/B or B/L No : ORIGIN :
MASTER W/B or B/L No : DESTINATION :
SHIPPING DATE : WEIGHT (KGS) :
DHL PRODUCT : INSURED VALUE (USD) :
CONTENTS (description):

INCIDENT DETAILS
DETAILED DESCRIPTION OF CLAIM :

LOCATION OF SHIPMENT :
(Address, contact name & tel. number)

INCIDENT TYPE (choose appropriate) :

AMOUNT CLAIMED (itemised) : Description Amount ( USD )
(including currency)

TOTAL AMOUNT CLAIMED ( USD ) : 0.00

COMMENTS :

NAME OF SUB-CONTRACTOR :
SUMMARY OF RECOVERY ACTIONS TAKEN AGAINST SUB-CONTRACTOR :

ATTACHED INFORMATION / DOCUMENTATION

CUSTOMER'S CLAIM LETTER INTERNAL TRACING INFORMATION
COPY OF SHIPMENT WAYBILL DAMAGE INSPECTION FORM
COMMERCIAL INVOICE INSURANCE CERTIFICATE (if applicable)
PACKING LIST (if applicable) PROOF OF SII PREMIUM PAYMENT
NOTICE OF CLAIM LETTER ISSUED TO SUB-CONTRACTOR (if applicable)
OTHER INFORMATION (please specify)

COMPLETED BY : LOCATION : EMAIL ADDRESS : TELEPHONE NUMBER :

DPWN GBS Risk Management, Bonn, January 2007 Ref: Notification of SII Claim v.8
 Notification of SII Claim Form - Completion notes

DATE : The date on which you are completing the form

DHL DIVISION :
SII POLICY NO :
CLAIMANT'S NAME :
CLAIMANT'S ADDRESS :
IDENTITY OF CLAIMANT :
CLAIMANT'S ACCT NO (if
applicable) :
Choose the contracting DHL division from the menu
The number of the SII policy providing the cover (if there is any doubt, this can be obtained from DPWN GBS Ri
Management / Dept. SD 711, in Bonn)
The name of the organisation bringing the claim against DHL
The full address, including postal or zip code
Choose the identity of the claiming party from the menu
The claimant's DHL account number

IF OTHER, SPECIFY IDENTITY

If the claimant is neither the shipper or receiver, clarify under what authority they are bringing the claim
AND RIGHT TO CLAIM :

CLAIMANT'S TEL NO : Contact telephone number, including area and country code where applicable. (If possible, specify a daytime numb

FAX NO : Contact fax number, including area and country code where applicable
CLAIMANT'S EMAIL : Contact email address

SHIPMENT DETAILS

HOUSE W/B or B/L No : The full house waybill or bill of lading number(s)
MASTER W/B or B/L No : The master waybill or bill of lading number(s), if applicable
ORIGIN : Town / city where DHL took possession of the shipment
DESTINATION : The intended final destination (town / city)
SHIPPING DATE : The date on which the shipment was passed to DHL

WEIGHT (KGS) : The weight of the shipment or, in the case of part/loss or damage, the weight of the affected item(s)

DHL PRODUCT : The DHL product on which the shipment was transported
INSURED VALUE The amount for which the shipment was insured

CONTENTS (description) A detailed description of the contents as declared on the waybill or customs documentation

INCIDENT DETAILS

DETAILED DESCRIPTION OF A summary of what happened to cause the claim (e.g.. part of shipment is missing and the delivered computer scre
CLAIM : cracked)

The address, contact name and telephone number of where the shipment is currently located. If the shipment is at t
LOCATION OF SHIPMENT :
claimant's address enter "As above", or if it is lost enter "N/A"

INCIDENT TYPE : Choose the most appropriate explanation for the type of incident that resulted in the claim from the menu

AMOUNT CLAIMED : Ensure you show the individual amounts claimed for each element of the claim (e.g.. Goods, Carriage), and the tot

COMMENTS : Please use this area to add any more information you believe is useful for the claim assessment

NAME OF SUB-CONTRACTOR
Where applicable, the name of the sub-contractor involved
:
 SUMMARY OF RECOVERY
Where a sub-contractor is involved, please use this area to advise what steps have been taken to protect our rights
ACTIONS TAKEN AGAINST
against the sub-contractor
SUB-CONTRACTOR :

ATTACHED INFORMATION

Indicate (by marking the appropriate box or boxes) what information you are sending with the form. As a minimum you should send a copy of the custo
letter and a copy of the waybill. It is important that you also keep copies of all this documentation

Please fill in your contact details in CAPITAL LETTERS to assist the insurer or DPWN GBS Risk Management, should they need to contact you direct

DPWN GBS Risk Management, Bonn, January 2007

 of SII Claim Form - Completion notes

pleting the form

vision from the menu
oviding the cover (if there is any doubt, this can be obtained from DPWN GBS Risk
n Bonn)
inging the claim against DHL
al or zip code
ing party from the menu
mber

pper or receiver, clarify under what authority they are bringing the claim

uding area and country code where applicable. (If possible, specify a daytime number)

area and country code where applicable

lading number(s)
ding number(s), if applicable
ossession of the shipment
own / city)
was passed to DHL

in the case of part/loss or damage, the weight of the affected item(s)

shipment was transported

ment was insured

ntents as declared on the waybill or customs documentation

o cause the claim (e.g.. part of shipment is missing and the delivered computer screen was

elephone number of where the shipment is currently located. If the shipment is at the
ove", or if it is lost enter "N/A"

planation for the type of incident that resulted in the claim from the menu

amounts claimed for each element of the claim (e.g.. Goods, Carriage), and the total amount.

more information you believe is useful for the claim assessment

he sub-contractor involved
ved, please use this area to advise what steps have been taken to protect our rights of recovery

you are sending with the form. As a minimum you should send a copy of the customer's claim
ies of all this documentation

e insurer or DPWN GBS Risk Management, should they need to contact you directly

Ref: Notification of SII Claim v.8