app.shipsurance.com
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172.66.0.83
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Submitted URL: http://www.verifyclaim.com/KbM9h0i
Effective URL: https://app.shipsurance.com/verifyclaim/?cid=shopify&claimId=SHP2Y-012724062810
Submission: On January 29 via manual from FR — Scanned from FR
Effective URL: https://app.shipsurance.com/verifyclaim/?cid=shopify&claimId=SHP2Y-012724062810
Submission: On January 29 via manual from FR — Scanned from FR
Form analysis 2 forms found in the DOM
Name: form — POST /verifyclaim
<form name="form" class="form-horizontal" method="post" action="/verifyclaim" id="SubmitClaimVerification">
<input id="ExtClaimId" name="ExtClaimId" type="hidden" value="SHP2Y-012724062810">
<input data-val="true" data-val-number="The field ptPersonId must be a number." id="ptPersonId" name="ptPersonId" type="hidden" value="6138">
<input id="cid" name="cid" type="hidden" value="shopify">
<input id="countryName" name="countryName" type="hidden" value="France">
<input id="locationState" name="locationState" type="hidden" value="Hauts-de-France">
<input id="locationCity" name="locationCity" type="hidden" value="Roubaix">
<input id="UserIPAddress" name="UserIPAddress" type="hidden" value="37.59.164.110">
<input id="actionFlag" name="actionFlag" type="hidden" value="viewClaim">
<div class="panel panel-primary">
<div class="panel-heading">
<h3 class="panel-title"><strong>Shipment Information for Claim Number: SHP2Y-012724062810</strong></h3>
</div>
<div class="panel-body">
<div class="row">
<div class="col-md-4" align="left"><strong>Reference #:</strong></div>
<div class="col-md-8"><span class="font_cellheader">615936722</span></div>
</div>
<div class="remove_row_padding">
<div class="row">
<div class="form-group">
<label for="claimReason" class="col-sm-4 control-label" style="text-align:left">What Happened to the Package?:<span class="color_red">*</span></label>
<div class="col-sm-5">
<select class="form-control input-lg" id="claimReason" name="claimReason">
<option value="">Please Select</option>
<option value="Damage">Item(s) Damaged</option>
<option selected="selected" value="Loss">Package Lost</option>
<option value="Shortage">Items Missing From Package</option>
</select>
</div>
</div>
<div class="form-group">
<label for="repairable" class="col-sm-4 control-label" style="text-align:left">If Damaged, Is/Are the Item(s) Repairable?:<span class="color_red">*</span></label>
<div class="col-sm-5">
<select class="form-control input-lg" id="repairable" name="repairable">
<option value="">Please Select</option>
<option value="Yes">Yes</option>
<option value="No">No</option>
<option value="N/A">Not Applicable</option>
</select>
</div>
</div>
<div class="form-group">
<label for="totalClaim" class="col-sm-4 control-label" style="text-align:left">Requested Resolution?:<span class="color_red">*</span></label>
<div class="col-sm-5">
<select name="resolution" id="resolution" class="form-control input-lg">
<option value="">Please Select</option>
<option value="Full">Full Refund – Total Loss</option>
<option value="Replacement">Replacement Item – Total Loss</option>
<option value="Partial">Partial Refund – Partial Loss</option>
</select>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="panel panel-primary">
<div class="panel-heading">
<h3 class="panel-title"><strong>Recipient / Buyer / Consignee Legal Statement</strong></h3>
</div>
<div class="panel-body">
<p><strong>To be signed by the recipient (damaged packages) or intended recipient (lost packages)</strong><strong> </strong></p>
<div class="alert alert-danger">
<p>
<strong> I certify that the information above is correct and truthful. I understand the consequences of fraud as described below.<br>
<br>Warning: Any fraudulent claims will make the shipper and/or consignee liable for any prosecution for mail fraud under federal crime code. The submission of a false, fictitious or fraudulent statement may result in imprisonment of up
to 5 years and a fine of up to $10,000.00 (18 USC 1001). In addition, a civil penalty of up to $5,000.00, and an assessment of twice the amount falsely claimed may be imposed (31 USC 3802). </strong>
</p>
</div>
<div class="remove_row_padding">
<div class="row">
<div class="form-group">
<label for="signedName" class="col-sm-4 control-label" style="text-align:left">Full Name of the(Intended) Recipient:<span class="color_red">*</span></label>
<div class="col-sm-5">
<input class="form-control input-lg " id="signedName" maxlength="30" name="signedName" placeholder="Recipient Full Name" type="text" value="">
</div>
</div>
<!-- Shipment Date Start -->
<div class="form-group">
<label for="signedDate" class="col-sm-4 control-label" style="text-align:left">Todays Date:<span class="color_red">*</span></label>
<div class="col-sm-3">
<div class="input-group date" id="datetimepicker8">
<input type="text" class="form-control input-lg" id="signedDate" placeholder="Todays Date" name="signedDate" data-format="MM/DD/YYYY">
<span class="input-group-addon"><i class="glyphicon glyphicon-calendar"></i></span>
</div>
</div>
</div>
<!-- Shipment Date END -->
<script type="text/javascript">
$(function() {
var currentTime = new Date()
var month = currentTime.getMonth() + 1
var day = currentTime.getDate()
var year = currentTime.getFullYear()
var todaydate = month + "/" + day + "/" + year
$('#datetimepicker8').datepicker({
todayBtn: "linked",
keyboardNavigation: false,
todayHighlight: true,
autoclose: true,
startDate: todaydate
});
});
</script>
<div class="row">
<div class="col-md-4" align="left"><strong>Your IP Address:</strong></div>
<div class="col-md-8">37.59.164.110</div>
</div>
<div class="row">
<div class="col-md-4" align="left"><strong>Your IP Location:</strong></div>
<div class="col-md-8">France - Hauts-de-France</div>
</div>
<div class="row">
<div class="col-md-4" align="left"><strong>Original Package Shipped To:</strong></div>
<div class="col-md-8"> FR</div>
</div>
<div class="row">
<div class="col-md-4" align="left"><strong></strong></div>
<div class="g-recaptcha col-md-8" id="html_captcha">
<div style="width: 304px; height: 78px;">
<div><iframe title="reCAPTCHA" width="304" height="78" role="presentation" name="a-rz9gp63u7wzl" frameborder="0" scrolling="no"
sandbox="allow-forms allow-popups allow-same-origin allow-scripts allow-top-navigation allow-modals allow-popups-to-escape-sandbox allow-storage-access-by-user-activation"
src="https://www.google.com/recaptcha/api2/anchor?ar=1&k=6Le7EtESAAAAABJO6dCKgXwil95VY3TWGJRnFzEW&co=aHR0cHM6Ly9hcHAuc2hpcHN1cmFuY2UuY29tOjQ0Mw..&hl=fr&v=QUpyTKFkX5CIV6EF8TFSWEif&size=normal&cb=i5ofssm92zyn"></iframe>
</div><textarea id="g-recaptcha-response" name="g-recaptcha-response" class="g-recaptcha-response"
style="width: 250px; height: 40px; border: 1px solid rgb(193, 193, 193); margin: 10px 25px; padding: 0px; resize: none; display: none;"></textarea>
</div><iframe style="display: none;"></iframe>
</div>
<br>
</div>
</div>
</div>
</div>
</div>
<p align="center"><button type="button" id="btnClaimVerification" value="Submit Claim Verification" class="btn btn-primary btn-lg">Submit Claim Verification</button></p>
</form>POST //translate.googleapis.com/translate_voting?client=te
<form id="goog-gt-votingForm" action="//translate.googleapis.com/translate_voting?client=te" method="post" target="votingFrame" class="VIpgJd-yAWNEb-hvhgNd-aXYTce"><input type="text" name="sl" id="goog-gt-votingInputSrcLang"><input type="text"
name="tl" id="goog-gt-votingInputTrgLang"><input type="text" name="query" id="goog-gt-votingInputSrcText"><input type="text" name="gtrans" id="goog-gt-votingInputTrgText"><input type="text" name="vote" id="goog-gt-votingInputVote"></form>Text Content
EMAIL CLAIMS SUPPORT Chat Support Translate this page: ▼ Please verify you are not a robot and make sure javascript is enabled in your browser. Verify Shipping Insurance Claim Please complete the form below. A shipping insurance claim has been submitted for claim #SHP2Y-012724062810. In order to continue processing this claim, we need the recipient, or intended recipient, to verify this is valid claim by completing the form below. Once complete, please click the "Submit Claim Verification" button. Alternatively, you can print out and manually submit our Claim Statement/Affidavit form. * Denotes Required Fields SHIPMENT INFORMATION FOR CLAIM NUMBER: SHP2Y-012724062810 Reference #: 615936722 What Happened to the Package?:* Please Select Item(s) Damaged Package Lost Items Missing From Package If Damaged, Is/Are the Item(s) Repairable?:* Please Select Yes No Not Applicable Requested Resolution?:* Please Select Full Refund – Total Loss Replacement Item – Total Loss Partial Refund – Partial Loss RECIPIENT / BUYER / CONSIGNEE LEGAL STATEMENT To be signed by the recipient (damaged packages) or intended recipient (lost packages) I certify that the information above is correct and truthful. I understand the consequences of fraud as described below. Warning: Any fraudulent claims will make the shipper and/or consignee liable for any prosecution for mail fraud under federal crime code. The submission of a false, fictitious or fraudulent statement may result in imprisonment of up to 5 years and a fine of up to $10,000.00 (18 USC 1001). In addition, a civil penalty of up to $5,000.00, and an assessment of twice the amount falsely claimed may be imposed (31 USC 3802). Full Name of the(Intended) Recipient:* Todays Date:* Your IP Address: 37.59.164.110 Your IP Location: France - Hauts-de-France Original Package Shipped To: FR Submit Claim Verification Copyright © 2003-2024 Shipsurance Insurance Services · 866-852-9956 · All rights reserved. Texte d'origine Évaluez cette traduction Votre avis nous aidera à améliorer Google Traduction