CARGO INSURANCE CLAIM FORM AND SUBROGATION AGREEMENT

Complete this CLAIM FORM as your cover page and submit it along with your claim documentation. If you need assistance with completing this claim form, feel free to contact us at the email address or phone number provided above. If cargo is received damaged or with contents missing, please attach 4 photos of 1) the container exterior 2) the container interior; 3) the internal packaging materials and 4) the merchandise (if available).

INSURER OR REPRESENTATIVE ("SUBROGEE"):

SHIPPER / ASSURED / CLAIMANT ("SUBROGOR"):

DECLARATION OF INSURANCE NUMBER:

CONVEYANCE:

BILL(S) OF LADING / WAYBILL #:

ORIGIN AND DESTINATION:

DATE OF LOSS:

UPS Capital Insurance Agency, Inc. on behalf of itself and all interested Underwriters subscribing to policy number (Policy Number)

(Assured)

(Policy Number again)

(Carrier)

(BOL / Tracking Number)

(Shipped From – Shipped To)

(Date of Delivery if not known)

Shipper Number: Pick-Up Date:

Cargo Status (check all that apply) Lost Damaged Missing Contents

Current Location of Package: Shipper Destination Unknown

Claimant’s Contact Name: Phone: E-Mail Address:

Comments/Detailed Packaging Description:

Destination Contact, Address, Email Address and Phone Number:

Merchandise Description and Quantity:

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UPSCIA P. O. Box 100458 Fort Worth, TX 76185-0458 Phone: 866-384-1852Email: upscapitalcargoclaims@ups.com

Merchandise Condition (New or Used): Declared Value: Weight:

Total Sales Invoice Amount: Claimed Sales Invoice Amount: Claimed Shipping Amount:

Total Amount of Claim:

Account you want payment sent to: Account # Bank Routing #

Required Supporting Documents: Commercial Invoice of Sale: Bill of Lading:

Proof of Loss of notification to the transportation carrier:

NOTE: No claims for loss or damage shall be valid unless the container, inner cartons, packing and contents have been served

and made available for inspection by a claims adjustor.

SUBROGATION AGREEMENT

1. CLAIMANT / SUBROGOR warrants and represents that:(a) it is the sole owner of the claims, demands, obligations and benefits set forth above and that said claims, demands,

obligations and benefits are free and clear of any liens or encumbrances; and(b) it has not released any third party from liability for the claims, demands, obligations and benefits set forth above or

accepted money from any third party for the claims, demands, obligations and benefits set forth above.2. CLAIMANT / SUBROGOR is entitled to enforce the terms of any transportation, storage, and/or bailment contract for the

above-described cargo.3. CLAIMANT / SUBROGOR has released no third party that is or may be for the loss of or damage to the above-described

cargo, including without limitation, any carrier, forwarder, broker, warehouseman.4. By accepting any claim payment, CLAIMANT / SUBROGOR:

(a) agrees that such claim payment shall be without precedent as to any other or future claim and shall be withoutprejudice to any rights, remedies or defenses inuring to SUBROGEE's benefit as to any other or future claim;

(b) releases SUBROGEE of any and all liabilities arising out of the above-described cargo and claim; and(c) assigns to SUBROGEE any and all of CLAIMANT / SUBROGOR's rights of recovery against all third parties,

without exception, for the loss of or damage to the above described cargo. SUBROGEE shall have all rights tocontrol and pursue recovery against those third parties. SUBROGEE, at its sole expense, is authorized to file alegal action(s) against such third parties in CLAIMANT / SUBROGOR's name, with the irrevocable power tocommence, prosecute, compromise, and/or withdraw any and all such actions. CLAIMANT / SUBROGOR shallreasonably assist and cooperate with any efforts of SUBROGEE to exercise the rights and remedies assigned andsubrogated by CLAIMANT / SUBROGOR hereunder, including without limitation, executing any and all documentsnecessary to enable the SUBROGEE to proceed with and maintain and conclude a legal action, providing relevantwitness testimony and providing requisite documentation always at CLAIMANT / SUBROGOR's expense, providedthat SUBROGEE shall reimburse CLAIMANT / SUBROGOR for any reasonable travel expenses incurred. Anyand all recoveries from third parties relating to the above-described cargo and claim, whether the SUBROGEE orCLAIMANT / SUBROGOR have first received them, shall be the sole property of the SUBROGEE, whether or notthere is a deductible under the policy or whether any portion of the loss or damage to the cargo is uninsured andthe SUBROGEE shall at its own discretion determine how any recovery proceeds shall be applied in accordancewith the terms of the policy.

By signing below, the undersigned warrants, represents, and covenants that the undersigned has the full and valid authority of CLAIMANT / SUBROGOR to enter into the terms of this Subrogation Agreement. The undersigned warrants, represents, and covenants that the information provided herein is correct to the best of their knowledge and that if any such warranty, representation or covenant shall for any reason become no longer valid then SUBROGEE will be promptly so informed in writing.

DATE:___________NAME/TITLE:_________________________________SIGNATURE:_______________________________________

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UPSCIA P. O. Box 100458 Fort Worth, TX 76185-0458 Email: upscapitalcargoclaims@ups.com

STEPS TO FILE A CLAIM

1. You are required retain all available damaged product, box and packing materials in order to be made

available in the event an inspection or survey becomes necessary. You are also required to take any

necessary steps to reduce or prevent further loss of the goods. Please see the Control of Damaged Goods and

Sue and Labor Clauses found in your insurance policy for further details.

2. For claims on UPS Small Package shipments, submitting your claim form to UPS Capital will satisfy the

requirement to put the transportation carrier on notice. For all other claims, promptly notify the

transportation carrier in writing that there was an issue with the shipment. Please see the sample notice letter

as a point of reference.

3. Promptly file your claim and supporting documents to UPS Capital in writing by fax or email immediately

after putting the transportation carrier on notice.

4. After filing a claim, you will receive a claim number and contact details of the adjustor to who the claim

has been assigned.

FREQUENTLY ASKED QUESTIONS

1. How will I know that my claim has been received?

a. You will receive a written acknowledgement of claim receipt by email within 48 hours. This

document will provide you with a UPS Capital Claim Number and will also identify which

adjuster your claim has been assigned to. In the event that you do not hear anything from our

office within 5 business days of submitting your claim, feel free to call us at 1 866 384 1852

b. 66b<> in order to confirm if we have received your claim.

2. What can cause my claim to be delayed?

a. All cargo insurance companies have three basic requirements before a claim can be paid.

i. Evidence that there was a loss or damage to the goods.

ii. Evidence to support the value of the claim.

iii. Evidence to support that the loss occurred during transit.

b. Failure to provide information or documents that have been requested in writing by a claims

adjuster may cause your claim to be delayed.

c. In the event of a damage claim, failure to retain the damaged cargo may result in a denial or a

delay in your claim.

3. How long will it take to receive payment?

a. As stated above, we strive to review and process all covered claims within a window of 5 business days

following initial receipt of your claim. If additional information is needed in order to review your claim

further, the adjuster will notify you in writing. Once your claim has been processed for payment, it could

take anywhere between 2 to 14 days to receive your payment. If you have received written notice that

your claim has been processed, but have not received your payment within 14 days, feel free to reach

out to our office.

4. What if I need assistance?

a. You may contact our office via email: upscapitalcargoclaims@ups.com or by phone: 1 866 384 1852

5. When will I know if a survey is required?

The insurance company has a right to request a survey generally on claims in excess of $5,000;however, a survey may be required on any claim.

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UPSCIA P. O. Box 100458 Fort Worth, TX 76185-0458 Email: upscapitalcargoclaims@ups.com

COMMON DOCUMENTS THAT MAY BE REQUESTED

Damaged Shipment

Freight

o Copy of Delivery Receipt

o Detailed Photos of Packaging, Label, and Damage to Cargo

o Repair Estimate (if applicable)

o Packing List (if applicable)

o Freight Invoice (if applicable)

o Replacement Invoice or Refund/Credit Memo (if applicable)

o Certificate of Destruction

Small Package

o Detailed Photos of Packaging, Shipping Label, and Damage to Cargo

o Repair Estimate (if applicable)

o Packing List (if applicable)

o Replacement Invoice or Refund/Credit Memo (if applicable)

o Certificate of Destruction

Lost Shipment

Freight

o Packing List (if applicable)

o Freight Invoice (if applicable)

o Replacement Invoice or Refund/Credit Memo (if applicable)

o Written Statement of Non-Receipt by Consignee (if applicable)

o Police Report

Small Package

o Packing List (if applicable)

o Replacement Invoice or Refund/Credit Memo (if applicable)

o Written Statement of Non-Receipt by Consignee (if applicable)

o Police Report

NOTE: Every claim is reviewed on its own merits. The list above is not intended to be an exhaustive list of all

possible documents required in support of your claim. Depending on the specific circumstances of your loss, additional information or documents may become necessary in order to property evaluate your claim. The claims adjuster will notify you in writing of any such requests.

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UPSCIA P. O. Box 100458 Fort Worth, TX 76185-0458 Email: upscapitalcargoclaims@ups.com