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发出此表并不代表保险人已经确认保险责任                        提单号:                                 
开口保单号:                                 
保险凭证/申报单号:                                 
被保险人名称:                                 
联系人姓名:                  电邮:                 
电话:                  传真:                
货物描述:                                 
货物存储地点:                                
损失描述:                                 
明显的损失原因:                                 
包装/堆放情况描述:                                  
由谁包装: 发货人                货运代理                  专业包装公司      其他方 (请详细说明)                                 
日期                                
何时从船/飞机卸下:                                  
收货人何时收货:                                  
何时发现损失/损坏:                                  
运输细节                                
从:                                      至:                           转运:     何种运输方式:                                                     船名:  航次                                
航空公司名称:                                                 航班号                    
拖运公司:                                 
铁路运输/其它:                                 
货运代理公司:                                  
报关代理:                                 
卸货站场:                                 
一般细节:                                 
在收到货物的时候，在送货单证上是否有破损记录: 有                  无