* = Required
Customer Name *
 Home Telephone *
 Office Telephone
New Address *
 City *
 State *
 Zip Code *
Old Address
 City
 State
 Zip Code
Email Address *
Order / Registration Number *     
 Load Date - MM/DD/YY
 Delivery Date - MM/DD/YY
Person To Contact
 Best Time To Contact
 Best Way To Contact
Did Employer Pay For Move?
 Employed By
  
What Was Declared Value Protection?
60¢/lb $1.25/lb $5.00/lb Lump Sum  $ Full Value Protection Don't Know
PLEASE LIST ALL ITEMS
** MAY NOT BE USED FOR DELAY OR PROPERTY DAMAGE CLAIMS **
Inventory #
Article Weight
Article Description*
Description of Loss/Damage*
Date of Purchase
Cost to replace
Amount Claimed*
Carton Damaged?

Remarks

I AM THE OWNER OF THE PROPERTY DESCRIBED. I DID NOT CAUSE OR CONTRIBUTE TO THE DAMAGE SET FORTH HEREIN. ALL STATEMENTS MADE IN THIS STATEMENT OF CLAIM AND ANY ATTACHED DOCUMENTS ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF, AND CONSTITUTE MY COMPLETE AND ENTIRE CLAIM. NO MATERIAL INFORMATION HAS BEEN WITHHELD. DOT REGULATIONS REQUIRE THAT ANY CLAIM FOR LOSS, DAMAGE OR DELAY MUST BE SUBMITTED IN WRITING BY CLAIMANT AND RECEIVED BY CARRIER WITHIN 9 MONTHS FROM DATE OF DELIVERY.

Submission of claim form constitutes signature of claimant. Any items not on claim form will not be allowed.