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Household Goods Claim Form  

Statement of Claim

* = Required to process claim
1.) * Reg/Lot/shipment #:
2.) * Customer Name:
3.) * Email Address:  (A copy will be forwarded to you)
4.) * New Address:
5.) * Old Address:
6.) * Home Telephone:
7.) Work Telephone:
8.) Fax Telephone:
9.) Cell Phone:
10.) * Loading Date:
11.) * Delivery Date:
12.) * Type of Move:
Interstate Move (State to State)
Local Move (Direct to new home)
Local Storage (Pickup and delivery)
Mississippi to Mississippi (Intra-state)
Mississippi to Mississippi (Intra-state) with Storage
Office / Industrial Move

12.) If employer paid for move, name of employer:      

13.) * Valuation Declared prior to move (if other than basic liability of $.60 /lb./article):
Replacement Value:
 $

14.) Please complete the following information for each item to be included in claim.

Item #1
Inventory # Description of Article Enter "Missing" or Damage description Wgt (LBS.)
From whom, where and date purchased
(indicate new or used)		 Purchase
Cost		 Replacement
Cost		 Amount
Claimed *
Item #2
Inventory # Description of Article Enter "Missing" or Damage description Wgt (LBS.)
From whom, where and date purchased
(indicate new or used)		 Purchase
Cost		 Replacement
Cost		 Amount
Claimed *
Item #3
Inventory # Description of Article Enter "Missing" or Damage description Wgt (LBS.)
From whom, where and date purchased
(indicate new or used)		 Purchase
Cost		 Replacement
Cost		 Amount
Claimed *
Item #4
Inventory # Description of Article Enter "Missing" or Damage description Wgt (LBS.)
From whom, where and date purchased
(indicate new or used)		 Purchase
Cost		 Replacement
Cost		 Amount
Claimed *
Item #5
Inventory # Description of Article Enter "Missing" or Damage description Wgt (LBS.)
From whom, where and date purchased
(indicate new or used)		 Purchase
Cost		 Replacement
Cost		 Amount
Claimed *
Item #6
Inventory # Description of Article Enter "Missing" or Damage description Wgt (LBS.)
From whom, where and date purchased
(indicate new or used)		 Purchase
Cost		 Replacement
Cost		 Amount
Claimed *
Item #7
Inventory # Description of Article Enter "Missing" or Damage description Wgt (LBS.)
From whom, where and date purchased
(indicate new or used)		 Purchase
Cost		 Replacement
Cost		 Amount
Claimed *
Item #8
Inventory # Description of Article Enter "Missing" or Damage description Wgt (LBS.)
From whom, where and date purchased
(indicate new or used)		 Purchase
Cost		 Replacement
Cost		 Amount
Claimed *
Item #9
Inventory # Description of Article Enter "Missing" or Damage description Wgt (LBS.)
From whom, where and date purchased
(indicate new or used)		 Purchase
Cost		 Replacement
Cost		 Amount
Claimed *
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