Sworn Affidavit

ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE MATERIAL FACT THERETO COMMITS A FRAUDULENT INSURANCE ACT WHICH IS A CRIME, AND SHALL ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION. PREMIER INSURANCE SERVICES LLC WILL ALERT LAW ENFORCEMENT AND STATE INSURANCE DEPARTMENT(S) IN THE EVENT OF INSURANCE FRAUD AND CLAIMANTS MAY BE SUBJECT TO ARRESTS, FINES, DISCIPLINARY ACTION AND/OR OTHER RAMIFICATIONS.

Premier Claims Handler(Required)

Premier Claim No.

Personal Information

Name(Required)

First Last

Email(Required)

Phone(Required)

Date of Birth(Required)

Drivers License / Identification No.(Required)

Company(Required)

Address(Required)

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

Loss Information

Date of Loss(Required)

Type of Loss(Required)

Ex. FedEx Priority Overnight Sending

Tracking / Reference Number(Required)

Ex. FedEx 1234 5678 9011

Description of Loss(Required)

Please insert complete details including dates, times, reference numbers, person(s) involved.

Ex. On June 2, 2021, we received an order for a 1.5 ct loose round diamond through our website from customer James Harrison. We issued Purchase Order No. 21-2934 to the transaction and prepared the item for shipment. The diamond was placed in a parcel paper then sealed in a small plastic ziplock bag. The ziplock bag was placed into a larger ziplock bag then secured in a FedEx bubble pouch. The UPS bubble pouch was secured in a small FedEx box and secured on all edges with clear packing tape. The shipment was dispatched on June 3, 2021 via FedEx Priority Overnight at the FedEx location on 1672 Biscayne Blvd., Miami, Florida 33131 and assigned FedEx Tracking No. 123456789. The shipment was routed through Nashville, TN but never delivered to the intended recipient.

Please Upload All Claims Documents

Invoices, Memos, Air WayBill, Shipping Label, Claims Forms, Letters, Photographs

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