Step 1 of 2 50% Name* First Last Order Number*Phone Number*Email Address*New Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Old Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Load Date* Date Format: MM slash DD slash YYYY Delivery Date* Date Format: MM slash DD slash YYYY Best Time to ContactBest Way to Contact*Did Employer Pay For Move?YesNoEmployed By: Please List All Items **May not be used for delay or property damage claims**Inventory Number or Tag ColorArticle WeightArticle DescriptionDescription of Loss/Damage* Be specificDate of Purchase/Proof of PurchaseCost to replaceClaimed Damage AmountIs shipping carton damaged? Click the + icon to add additional rowsComments:I AM THE OWNER OF THE PROPERTY DESCRIBED. I DID NOT CAUSE OR CONTRIBUTE TO THE DAMAGE SET FORTH HEREIN. ALL STATEMENTS MADE IN THIS STATEMENT OF CLAIM AND ANY ATTACHED DOCUMENTS ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF, AND CONSTITUTE MY COMPLETE AND ENTIRE CLAIM. NO MATERIAL INFORMATION HAS BEEN WITHHELD. DOT REGULATIONS REQUIRE THAT ANY CLAIM FOR LOSS, DAMAGE OR DELAY MUST BE SUBMITTED IN WRITING BY CLAIMANT AND RECEIVED BY CARRIER WITHIN 9 MONTHS FROM DATE OF DELIVERY. Submission Signature of Consent* I Agree To The Terms & Conditions.
