BullionMax New Claim Form

BullionMax New Claim

Please complete all fields with detailed information and check for accuracy.

Hidden

Insured's Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Hidden

Policy Begin Date

Hidden

Policy End Date

Hidden

Deductible

Submitter Contact Information

Name(Required)

First Last

Email(Required)

Phone(Required)

Loss Details

Order No. / Reference No.(Required)

Type of Loss(Required)

Date of Loss(Required)

Type of Loss - Other

Brief Description of Package Contents(Required)

What happened to the shipment?(Required)

Package last scanned in which city?

Package last scanned on what date?

How were the contents secured?(Required)

Coverage Limit(Required)

Loss Amount(Required)

Claim Amount (net of $250 deductible & carrier reimbursement)(Required)

Shipment Details

Shipping Company(Required)

Shipping Service

Tracking Number(Required)

Dispatch Date(Required)

Expected Delivery Date(Required)

Was shipment insured with the shipping company?(Required)

Yes

Has the shipping company reimbursed you for the loss?(Required)

Yes

How much did the shipping company pay?

Shipper Details

Who actually dispatched the shipment?

Company Name(Required)

From which city?(Required)

State(Required)

Shipping Label Details

Shipper Name / Company(Required)

Recipient Name / Company(Required)

Shipper Address(Required)

Street Address Address Line 2 City State ZIP Code

Recipient Address(Required)

Street Address Address Line 2 City State ZIP Code

Additional Information

Upload Claim Documents

Drop files here or

Max. file size: 32 MB.

Purchase Invoice(s), Shipping Label, Photos of Shipment (if damaged/tampering), Shipping Carrier Claim Form, Correspondence with Carrier, Police Report (if applicable) and Other Relevant Documentation

CAPTCHA