Claim Form


Claim Form Instructions for Intra-state Moves

Please read carefully before filing claim

Transportation Losses
This presentation of claim form is provided to aid in compliance with the terms of the bill of lading. Before presenting a claim for loss and damage, review the terms and conditions of the bill of lading under which the property was accepted for transportation.

To refund or remit in any manner or by any device, any portion of the rates and charges so specified through the payment of fraudulent, fictitious or excessive claims for loss or damage to merchandise transported is as much a violation of law as is direct concession or departure from the published rates and charges.

Warehouse Losses
A warehouse company is not an insurer of customers' property in storage. The law provides that a warehouse concern is only liable for loss or damage in case of failure to exercise ordinary care.

Warehouse charges are based upon a limitation of liability. This limitation is clearly set forth in your warehouse receipt contract.

Insured Losses
The above limitations do not apply providing you were issued a Certificate of Insurance covering your goods while in storage or if you were issued a Certificate of Insurance covering an intra-state transportation of goods.
* Indicates a required field.
Claim Form
Name of Claimant*
Address of Claimant*
Phone*
 
Alt. Phone
Email:*
 
Do you have a certificate ?
Yes / No
Are you the owner ?  
Yes / No
Was your shipment in a warehouse ?  
Yes / No
 
Shipment Total Weight:
 
Packed by:    
Date Packed:
  
 
Date Shipment was Picked-Up:
  
 
Origin Address
Address*
Apt / Suite
City*
State*
Zip
 
Name of Storage Company:
Address/Location of Warehouse:
 
Date Placed in Storage:
  
Date Removed from Storage:
  
Date Delivered:
  
 
Destination Address
Address
Apt / Suite
City*
State*
Zip
 
Unpacked by:    
Date Unpacked:
  
 
 
Date Damage/Shortage Discovered:
  
By Whom:
Kind and/or Cause of Damage:
Details of Claim
How many items do you need to claim? *
The inventory number is very important. Please show the number that was attached to the article when loaded at origin. On packed items, indicate the container item number.

State the name of the article, such as “small carton,” “triple dresser,” etc. Use same name as on inventory or show corrected two names.

If a shortage is claimed – give a complete description including color, size, shape, model numbers, manufacturer’s name, etc., which will be used for tracing back to origin. Also state where purchased, cost when new, cash value at time of loss, considering depreciation and other factors. Immediate reporting of claimed missing items is very important. If a carton; identify contents of container and inventory item number (tag number) and any identifying marks that may be unusual.

If the article is damaged, again be sure to give full description, color, size, shape, model number, manufacturer’s name, etc. Explaining the exact location such as “top right front corner,” “bottom left side panel,” etc. Sofas and chairs are described left or right – facing the article- NOT from a sitting position. This is necessary to compare the origin inventory to determine new or pre-existing damage. On packed items, indicate whether the container was damaged and the extent of any damage, as above.

If actual weight is not available, give an estimate.

Settlement may be expedited if original sales tickets or appraisals or identical articles or affidavits as to the value accompany this form and the information is inserted in columns.

Estimated Cost of Repairs – Claimant’s estimate should be noted. If an estimate from a qualified repairman or appraiser is available – please include a copy in this report.
Item 1
Inventory No.
Article Description
(include serial #, color, size, etc.)
Was it packed in a box?  Yes / No
Description of Damage
(scratched, chipped, etc.)
Where was item purchased?
(If available provide name and address)
Age of article or date purchased
Weight of article lbs
Cost New (or appraised value) $
Replacement Cost Today $
Est. cost of repairs and/or amount claimed $
Item 2
Inventory No.
Article Description
(include serial #, color, size, etc.)
Was it packed in a box?  Yes / No
Description of Damage
(scratched, chipped, etc.)
Where was item purchased?
(If available provide name and address)
Age of article or date purchased
Weight of article lbs
Cost New (or appraised value) $
Replacement Cost Today $
Est. cost of repairs and/or amount claimed $
Item 3
Inventory No.
Article Description
(include serial #, color, size, etc.)
Was it packed in a box?  Yes / No
Description of Damage
(scratched, chipped, etc.)
Where was item purchased?
(If available provide name and address)
Age of article or date purchased
Weight of article lbs
Cost New (or appraised value) $
Replacement Cost Today $
Est. cost of repairs and/or amount claimed $
Item 4
Inventory No.
Article Description
(include serial #, color, size, etc.)
Was it packed in a box?  Yes / No
Description of Damage
(scratched, chipped, etc.)
Where was item purchased?
(If available provide name and address)
Age of article or date purchased
Weight of article lbs
Cost New (or appraised value) $
Replacement Cost Today $
Est. cost of repairs and/or amount claimed $
Item 5
Inventory No.
Article Description
(include serial #, color, size, etc.)
Was it packed in a box?  Yes / No
Description of Damage
(scratched, chipped, etc.)
Where was item purchased?
(If available provide name and address)
Age of article or date purchased
Weight of article lbs
Cost New (or appraised value) $
Replacement Cost Today $
Est. cost of repairs and/or amount claimed $
Item 6
Inventory No.
Article Description
(include serial #, color, size, etc.)
Was it packed in a box?  Yes / No
Description of Damage
(scratched, chipped, etc.)
Where was item purchased?
(If available provide name and address)
Age of article or date purchased
Weight of article lbs
Cost New (or appraised value) $
Replacement Cost Today $
Est. cost of repairs and/or amount claimed $
Item 7
Inventory No.
Article Description
(include serial #, color, size, etc.)
Was it packed in a box?  Yes / No
Description of Damage
(scratched, chipped, etc.)
Where was item purchased?
(If available provide name and address)
Age of article or date purchased
Weight of article lbs
Cost New (or appraised value) $
Replacement Cost Today $
Est. cost of repairs and/or amount claimed $
Item 8
Inventory No.
Article Description
(include serial #, color, size, etc.)
Was it packed in a box?  Yes / No
Description of Damage
(scratched, chipped, etc.)
Where was item purchased?
(If available provide name and address)
Age of article or date purchased
Weight of article lbs
Cost New (or appraised value) $
Replacement Cost Today $
Est. cost of repairs and/or amount claimed $
 
Total amount claimed
$
The amount of valuation I took out covering
my household goods was
$
The actual value of my household goods was
$
My deductible amount was
$
 
You can send us scanned documents or digital images to assist us in processing your claim.




I am the owner of the property described above. I did not cause or contribute to the damages set forth herein. All statements made in this statement of claim and any attached photographs or 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. All loss, damage or delay must be filed in accordance with the Contract Terms and Conditions.