Initial Claim Notification

Mr.  Mrs.  Ms.  Miss  Dr.
*First Name:		*Last Name:
Phone:		Fax:
*E-mail:
Address:
Confirmation of Insurance #:
Santa Fe Job Reference #:

PLEASE LIST BELOW ALL OF THE ITEMS YOU INTEND TO CLAIM FOR INCLUDING DETAILS OF THE NATURE OF THE LOSS/DAMAGE SUSTAINED TO EACH ITEM I.E. BREAKAGE, PILFERAGE, WATER DAMAGE, INTERNAL DAMAGE, ETC.

Number of Lines  Add  Delete
	Description of Item	Nature of Loss/Damage Substained	Approx. Cost of Repair/Replacement
1
2
3
4
5
Important: You must retain all damaged items until your claim has been settled. Failure to do so may result in your claim being prejudiced.

*Please select a 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 initial notification form.  Yes  No

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No signature is required as this initial claim notification is submitted online.