Claim Form - Texas local and Texas intra-state moves only.

Claim Form - Texas local and Texas intra-state moves only.

For assistance, please email claims@olerrelo.com or call 713.939.1448
Name

First NameLast Name
New Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Old Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number Home
Please enter a valid phone number.
Phone Number Office
Please enter a valid phone number.
Phone Number FAX
Please enter a valid phone number.
Pick-up date

MonthDayYear
Date
Delivery Date

MonthDayYear
Date
Was Shipment in Warehouse?

YESNO
Did employer pay for the move?

YESNO
If employer paid, what's their name?
Valuation and Article Claims
Valuation Amount Declared $.60/lb/article FVP-A no deductible
FVP-Bwith deductible. Valuation amount declared $ fill in amount

List Items Claimed Lost or Damaged 1

	Inventory number	Article Weight	Article Description	Description Loss or Damage	Date of Purchase/ Age of Item	Cost to Replace	Amount Claimed	Was Carton Damaged?
fill out the blanks >>>>>

List Items Claimed Lost or Damaged 2

	Inventory number	Article Weight	Article Description	Description Loss or Damage	Date of Purchase/ Age of Item	Cost to Replace	Amount Claimed	Was Carton Damaged?
fill out the blanks >>>>>

List Items Claimed Lost or Damaged 3

	Inventory number	Article Weight	Article Description	Description Loss or Damage	Date of Purchase/ Age of Item	Cost to Replace	Amount Claimed	Was Carton Damaged?
fill out the blanks >>>>>

List Items Claimed Lost or Damaged 4

	Inventory number	Article Weight	Article Description	Description Loss or Damage	Date of Purchase/ Age of Item	Cost to Replace	Amount Claimed	Was Carton Damaged?
fill out the blanks >>>>>

List Items Claimed Lost or Damaged 5

	Inventory number	Article Weight	Article Description	Description Loss or Damage	Date of Purchase/ Age of Item	Cost to Replace	Amount Claimed	Was Carton Damaged?
fill out the blanks >>>>>

List Items Claimed Lost or Damaged 6

	Inventory number	Article Weight	Article Description	Description Loss or Damage	Date of Purchase/ Age of Item	Cost to Replace	Amount Claimed	Was Carton Damaged?
fill out the blanks >>>>>

List Items Claimed Lost or Damaged 7

	Inventory number	Article Weight	Article Description	Description Loss or Damage	Date of Purchase/ Age of Item	Cost to Replace	Amount Claimed	Was Carton Damaged?
fill out the blanks >>>>>

List Items Claimed Lost or Damaged 8

	Inventory number	Article Weight	Article Description	Description Loss or Damage	Date of Purchase/ Age of Item	Cost to Replace	Amount Claimed	Was Carton Damaged?
fill out the blanks >>>>>

List Items Claimed Lost or Damaged 9

	Inventory number	Article Weight	Article Description	Description Loss or Damage	Date of Purchase/ Age of Item	Cost to Replace	Amount Claimed	Was Carton Damaged?
fill out the blanks >>>>>

List Items Claimed Lost or Damaged 10

	Inventory number	Article Weight	Article Description	Description Loss or Damage	Date of Purchase/ Age of Item	Cost to Replace	Amount Claimed	Was Carton Damaged?
fill out the blanks >>>>>

List Items Claimed Lost or Damaged 11

	Inventory number	Article Weight	Article Description	Description Loss or Damage	Date of Purchase/ Age of Item	Cost to Replace	Amount Claimed	Was Carton Damaged?
fill out the blanks >>>>>

List Items Claimed Lost or Damaged 12

	Inventory number	Article Weight	Article Description	Description Loss or Damage	Date of Purchase/ Age of Item	Cost to Replace	Amount Claimed	Was Carton Damaged?
fill out the blanks >>>>>

File Upload

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IMPORTANT NOTICE: TXDOT regulations require that any claim be submitted in writing and received by carrier within 90 days from delivery of the shipment to the final destination or after a reasonable time of delivery has elapsed in case of failure to make delivery.
Oler Relo Group | 12337 Cutten Road, Houston, TX 77066 | 713-939-1488
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Valuation and Article Claims