Shipment Insurance Receiver Form

STEP 1 OF 7

Shipment & insurance

Enter the shipment details and registered value.

Shipment / tracking number

Insurance policy / reference number (optional)

Registered / insured value

Currency

Number of packages

Shipment date (optional)

Insurance purchase / payment date (optional)

Package description

STEP 2 OF 7

Sender information

Provide the contact details of the person or business sending the package.

Sender full name / company name

Sender street address

Sender city

Sender state / province

Sender ZIP / postal code

Sender country

Sender phone

Sender email

STEP 3 OF 7

Receiver information

Choose the receiver type to display the appropriate identification fields.

Receiver type

Receiver street / business address

Receiver city

Receiver state / province

Receiver ZIP / postal code

Receiver country

Receiver phone

Receiver email

STEP 4 OF 7

Identity & company verification

Upload clear, complete documents for agency review. The requirements depend on your receiver type.

Files are encrypted in storage and accessible only to authorized site administrators. Maximum 3 MB per file and 6 MB for all files combined, including package documents. Accepted formats: PDF, JPG, PNG; selfies: JPG or PNG.

These documents support a manual review by the agency. Uploading them does not automatically verify your identity or approve insurance coverage, a claim, or shipment release.

STEP 5 OF 7

Insured property & documents

Describe the insured items. Upload invoices or package photos if available.

Insured item description

Item quantity

Make / model (optional)

Serial / VIN / identification number (optional)

Purchase / invoice value (optional)

Invoice / order number (optional)

Supporting documents / photos (optional)

Up to 3 invoices or package photos. Maximum 3 MB each and 6 MB for all files combined. PDF, JPG, or PNG. Use the Verification step for identity or company documents.

STEP 6 OF 7

Claim or release details

Tell us why you are submitting this form. Claim details are optional for registration.

Reason for submission

Incident date (optional)

Claim amount requested (optional)

Description of circumstances / additional notes (optional)

STEP 7 OF 7

Review & certify

Review your information before signing and submitting.

Electronic signature — type your full legal name

Signature date

I certify that the information and documents I have provided are accurate to the best of my knowledge, and I authorize Ron Dennison Insurance Agency INC to review them for this shipment inquiry and identity or company verification. By typing my name above, I intend it to serve as my electronic signature.

Submission does not create or confirm insurance coverage, approve a claim, or authorize the release of a shipment. The agency will review your information and contact you if needed.