Claim Form

Important: Please read the instructions on page entitled Claims Reporting Procedures, then complete Claim Form carefully and accurately.
Mr.  Mrs.  Ms.  Miss  Dr.
*First Name:		*Last Name:
Address:
Phone Residence:		Phone Business:
Fax:		E-mail:
Packing Date: (YYYY-MM-DD)	From - - To - -
Delivery Date: (YYYY-MM-DD)	From - - To - -
Enrolment Certificate #:
Santa Fe's Reference #:

Number of Lines  Add  Delete
Category on Valued Inventories (e.g. living room)	Number on Packing List	Description of Item	Please Specify Nature of Damage or Loss Sustained (e.g. missing, broken, chipped, internal damage)	Replacement Cost as New at Destination	Covered Value	Amount of Claim (please specify currency)
Total Amount Claimed: (Please specify currency)

*Please select Santa Fe office you want to submit to:  -- Select -- China Hong Kong India Indonesia Japan Macau Malaysia Philippines Singapore South Korea Taiwan Thailand Vietnam

I want to have a copy of my Claim form.  Yes  No

If yes, please specify e-mail:

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No signature is required as this Claim form is submitted online. I/We, hereby make a solemn oath to the statements contained herein and exhibits attached hereto, and that no material fact is withheld that should be included in this report. This also is to certify that I/we have not received any merchandise claimed short/missing from any source, to date. Should I/we receive this merchandise, from any source, I/we will promptly notify Santa Fe and delete the items from the claim, or if claim has been paid, I/we will return the monies paid. I / We acknowledge that Santa Fe, as the holder of the Group Policy, will submit the claim to the Underwriters or the policy administrator for further processing.