Standard Proof of Loss and Damage Claims

Standard Proof of Loss and Damage Claims

Under Uniform Household Goods Bill of Lading
Customer Information
Email Adress*
example@emial.com
Name*

First NameLast Name
Phone Number.*
Mailing address.*

Address Line

Address Line 2

CityState

Zip Code
Information About Move
Order Number *
Please specify your move type:*

In-stateOut-of-StateInternational
Moving Company Name*
Pick-Up Date

AyGünYıl
Delivery Date

AyGünYıl
From Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Did the moving company store the items?*

YesNo
Where and how long did these items stored?
(Place - xxx days/months etc.)
To Address

Same as Mailing AddressOther
To Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Could you please tell us which protection plan you chose for your belongings on the moving day?*

Released Value Protection 30 cents per lbsReleased Value Protection 60 cents per lbsFull Value Protectioni did not select any coverageI don't know what this is
Reason for Claim*

LossDamageOverchargeGreivanceDelay
Statement of Claim
Select the claim type

Damaged ItemsDamaged PropertyBoth
ITEMS
List of damaged items:*
Do you have any images to show damage? (Items without supporting pictures may be denied )

YesNo
Please provide the following photos: One clear picture showing the specific damage. One picture showing the entire item.

Cancelof
PROPERTY
List of damaged property:
Describe the damages in detail
Do you have any images to show damage?

YesNo
Please upload the images which shows damages. (Proprety damages without 2 supporting pictures may be denied )

Cancelof
Please upload at least 3 repair estimates. (Proprety damages without 3 estimates may be denied )

Cancelof
LOSS
List of lost items:*
Do you have any images of lost items?

YesNo
Please upload the images which shows the lost items. ( Optional )

Cancelof
OVERCHARGE
Reason for Overcharge
Describe the reason for overcharges in detail
Claimed Amount $
GRIEVANCE
Describe the reason for grievances in detail
Claimed Amount $
DELAY
Describe the reason for delay in detail
Claimed Amount $
Do you have additional insurance?*

NoYes
Will you be filing a claim through a third-party insurance policy?

Yes, I have.Yes, I will.No, I will not
If YES is answered to either of these questions, all claims processing must be done by the applicable insurance company, which will compensate you directly. Once compensated, your insurance company will take a subrogated position to seek reimbursement from the Moving Company. You understand that in this event, you will collect from your 3rdparty insurance ONLY, and cannot then place a subsequent claim with the Carrier. We will cooperate with your insurance company fully to assist in resolving your claim.
Insurance Company Name
Insurance Company Phone
Please upload moving documents: Estimate for Service, Bill Of Lading, Valuation Addendum, Inventory List. ( If applicable Packing Material Order Form, Revised Written Estimate )*

Cancelof
Amount
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Standard Proof of Loss and Damage Claims

Customer Information

Information About Move

Statement of Claim

ITEMS

PROPERTY

LOSS

OVERCHARGE

GRIEVANCE

DELAY