Presentation of Loss and Damage Claim

 

Contact Information

* Required Fields

*Relocation Date: 

*Relocation Type:  
*Service:  
*Registration #:  
*Claimant: 
Name:   (if different from claimant)
*Address: 
Apt#: 
*City: 
*State: 
*Zip Code: 
* Phone #: 
Alternate Phone#: 
*E - Mail: 

Additional Information

Date at Origin  :   
Articles were packed by:  (if applicable)
Origin Address:
City: State:
 
Date at Destination: 
Articles were unpacked by: (if applicable)
Destination Address: 
City: State: 

State where shipment was temporarily in storage:        

*Declared Value for Entire Shipment       

  Inventory #     Article 

Describe Loss or Damage

 Weight Date Acquired

Original Cost

 Amount Claimed
1

 
2
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4
5
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7
8
9
10

Additional comments:

The submitter hereby makes a solemn oath to the truth of the statements contained herein, and exhibits attached hereto, and that no material fact is withheld that should be included in this report.  For the purpose of obtaining money on the above claim I hereby demand: which is to be considered as a full release and discharge from any and all claims and demands accruing prior to this claim, and particularly from any and all claims and demands rising out of the transportation described in the foregoing statement.

I understand that this is my full and final claim.

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