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  • U-PIC Insurance Services Affidavit
    For Lost or Damaged Parcels

    CLAIM INFORMATION SHEET

    Order Number: * Name: *
    Street Address / P.O. Box: *
    City: * State / Province: * Zip Code
    *
    Phone: * Contact: E-Mail
    *

    CLAIM DETAIL

    Lost / Damage / Incomplete:
    If item is damaged, please describe and attach picture of damage:
    Describe condition of package:
    I hereby certify that all information on this form is accurate and truthful. 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).
    Signature: * Date: *
    Those customers filing more than one claim may experience a delay in payment due to an increase in investigative time.

    WARNING: ANY FRAUDULENT CLAIMS WILL MAKE THE SHIPPER AND/OR CONSIGNEE LIABLE FOR ANY PROSECUTION FOR MAIL FRAUD UNDER FEDERAL CRIME CODE.  

    Re-send or refund policy:
    Please check one only for resend or refund
    1. Resend

    All order under $10.00 will refund only.

    2. Refund

    U-PIC Insurance Services
    18961 E. Arenth Ave. City of Industry, CA  91748 Phone: 626-912-0668
    Email: order@abcink.com

     
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