Claim Form

For damaged or lost parcels please fill out the following claim form.
We are required to wait 30 days to file a claim for insured mail.

Required fields are underlined

Email^*

Confirm Email^*

First Name^*

Last Name^*

Street Address^*

State

Country

Zip^*

Telephone^*

ProductID#1^*

Damaged

Lost

ProductID#2

Damaged

Lost

ProductID#3

Damaged

Lost

ProductID#4

Damaged

Lost

ProductID#5

Damaged

Lost

Date Shipped

Leave blank if not shipped

Your Comments

I certify that the above statements are true

If you have questions, email us at claims@nickolai-gurgeiff.com