Online Claim Form

Your claim has been submitted. Your claim ID is XXX and a copy has been emailed to the supplied email address.

Please correct the highlighted fields.

Claim Information

*indicates required

Name of Recipient/Consignee

Type of Issue*:

Date Issue Occurred

Merchant ID (if available)

Order Number

Tracking Number

Value being claimed*

Currency

Describe Your Issue*

Order Information

Date of Order

Items/Service Purchased*

Item(s)/Service Cost

Shipped Date (if available)

Delivery Date (if available)

Address 1

Address 2

City

State

Zip

Country*

On what website did you purchase the items/services?

Claim Correspondence Contact (updates and claim notices will be sent to the email address below)

Email*

Confirm Email*

Phone Number

Additional Comments

Opt-in for electronic notice and decisions on your claim. By checking this box, you agree to receive updates and decisions for your claim only by electronic means. You also agree that your computer is fully able to access and read PDF files used for these notices. Should you wish to opt-out of the paperless service, you may do so by emailing [email protected].

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Online Claim Form

Claim Information

Order Information

Claim Correspondence Contact (updates and claim notices will be sent to the email address below)