Submit Claim Filing Date:(Required) MM slash DD slash YYYY Pick Up Date:(Required) MM slash DD slash YYYY Delivery Date:(Required) MM slash DD slash YYYY Name:(Required) Email:(Required) New Address:(Required) Origin Address:(Required) Home Phone:(Required)Cell Phone:(Required)Moving Company:(Required) Address:(Required) Phone Number:(Required)Contact:(Required)list(Required)Inventory NumberArticleDescription of DamageWeightAge/Date PurchasedOriginal CostAmount Claimed Add RemoveTotal Claimed(Required) Claim Submission Instructions All claims for a Local move must be filed with the Carrier within thirty (30) to ninety (90) days (depending upon your Carrier’s policy) from the date of the move. All claims for an Interstate move must be filed with the Carrier within nine (9) months from the date of the move. Shippers may only submit one claim submission. Please complete Page 1 of the claim form in its entirety, sign Page 2, and return with any supporting documentation including, but not limited to, the following: Photographs: Clear photos including a photo of the entire item(s) and a separate photo(s) of the damages. Labeling: Each photo must be identified reflecting a full description of the damages, i.e. chair, left leg scratched; table, right edge dented, etc. In describing items, provide as much detail as possible including but not limited to age, value, make, model number, color, size, material, etc. A separate sheet of paper may be used for additional information. Photograph Submission: Each photograph must be attached to an email in JPEG format. Do not embed the photographs within an email. Do not provide thumbnail images. Do not provide black and white images. Proof of Purchase: Copies of receipts and/or proof of purchase which is generally available at the retail establishment where purchased. Manufacturer’s Labels: Copies of manufacturer’s labels for appliances, electronics, mechanical items, etc. Property Damage: With respect to property damage, please identify as to origin and/or destination address. Please identify the area of the residence, i.e. Foyer, Master Bedroom, Basement. Please do not discard any packing materials, cartons, or damaged items listed on your claim form until the resolution of this claim has been concluded. Shipper must retain all damaged items until final resolution of the claim. The repairs and/or replacement of items and/or property will not be honored without pre-approved written authorization. All moving services must be paid in full prior to the start of the claim process. Should your claim concern matters other than loss and/or damage, kindly complete the top portion of the claim form, sign the second page, and detail your issues within a separate document. Upon receipt of your claim, we will begin the process of resolution. Shipper waives any rights including but not limited to chargebacks, offsets, holds, rejection, and denial of the credit card charges and/or the filing of a similar action with the credit card and/or financial establishment with respect to moving services provided and/or any claims and/or a favorable claim resolution. Shipper further acknowledges and agrees that all claims are subject to full payment of services and that no claim shall be addressed until full payment of services. I/we, the undersigned, own the property described. The undersigned hereby swear that the above information on this form and any additional attached supporting documents is true and correct to the best of my/our knowledge and constitutes my/our complete and entire claim. The undersigned does further swear no information has been withheld or misrepresented. If it is determined that any of the above or additional attached supporting documents is false, or material facts withheld or misrepresented, it is agreed this shall justify in part or in whole the denial of this claim.Signature(Required)Date(Required) MM slash DD slash YYYY
