Claims Form

The "Presentation of Claim" form is provided to aid compliance with the terms of the bill of lading or warehouse receipt. Before presenting your claim, review the terms and conditions under which the property was accepted for transportation or storage. Unless otherwise authorized in advance by the carrier, claims will not be fully settled until all freight charges have been paid. If available, please attach a copy of your bill of lading, warehouse receipt or inventory. Claim Instructions

Your Information

Claimant:	New Address:	Home Telephone:	Work Telephone:

City:	State:	Zip:	Email:

Moving Co. Name/Location:		If Billed Order Name of Company:

Shipment Ref. No:	Load Date:	Delivery Date:

Old Address:	Old City:	Old State:	Old Zip:


Indicate what percentage of the cartons were carrier packed: %

Valuation Coverage Declared

Please review shipping or storage documents to determine correct valuation, and indicate in the area below:
	Basic coverage at .60 per lb. per article.
	Full Value, No Deductible, Amount Declared $
	Full Value with deductible.Deductible $ Amount Declared $

1. Inventory Number	2. Article/ CTN. WGT.	3. Article Description Include all Pertinent Information such as make, model, pattern, serial # etc.	4. Loss/Damage Description Indicate damage location and possible cause if reporting a shortage indicate Short or Missing, electrical or mechanical damage may require an addtional damage report.	5. Age/ACQ Date	6. Original and Replacement Cost O / R	7. Amount Claimed
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If payment for shortage item(s), is made and shortage item(s) (Except perishable and items requiring immediate permanent receplacement) are subsequently delivered to the claimant within a reasonable period of time, claimant agrees to accept the items. Should claimant wish to collect damages on any of the returned items, the claimant must file a new and separate claim form.

The actual cash value of my shipment was $

Sub Total
Total
Date

Comments/Questions:

Certification: By choosing the Agree Buttong button below, I certify I am the owner of the property described and I did not cause or contribute to the damage set forth herein. I also, declare that all statements made in the 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.

AgreeDisagree

Note: If this form is not thoroughly completed, it may be returned, delaying process of claim.