Claim Notification - Gladstone Agencies Limited.

Claim Notification / Survey Application Form

Applicants

Contact Person

Address

City

State

Pin Code

Phone No.

Fax No.

E-mail

Please provide information about your claim :

Location of Survey

Approx. Loss Amount

Consignment

Vessel

Insurance Co.

Policy No.

Upload scanned copies of the following (optional - file size limit 1 MB per file) :

Insurance Policy

Invoice

Packing List

Bill of Lading

Photographs

Any other information on the loss