Customer Name *

Home Phone *

Work Phone

Email *

New Address *

City *

State *

Postal code *

Old Address *

Address
City
State
Postal Code

Delivery Date *

Pick-up Date *

DID EMPLOYER PAY FOR MOVE? *

Yes

EMPLOYED BY

WHAT WAS DECLARED VALUE PROTECTION? *

0.30/lb

FULL VALUE PROTECTION

DEDUCTIBLE

How many items? *

Inventory number *

Article weight

Article description *

Date of purchase/ Age of item

Description of loss / damage *

Inventory number 2

Article weight 2

Article description 2

Date of purchase/ Age of item 2

Description of loss / damage 2

Inventory number 3

Article weight 3

Article description 3

Date of purchase/ Age of item 3

Description of loss / damage 3

Cost to replace *

Amount claimed *

Carton damaged? *

Yes

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 knowledge and belief, and constitute my complete and entire claim. No material information has been withheld. Any claim for loss, damage, or delay must be submitted in writing by claimant and received by carrier within 30 days from date of delivery.

Date