PRESENTATION OF CLAIM FOR LOSS AND DAMAGE

INSTRUCTIONS TO CLAIMANT

UNITED Van Lines

Rossiter Relocation Services

6475 Las Positas Road, Livermore, CA  94551

CARRIER REFERENCE NUMBER

  1. Print or type full particulars to the best of your knowledge.

  2. Any articles found damaged must be kept available for inspection (including containers).

  3. In describing articles, give as much information as possible such as color, kind of material, model numbers, trade/name, manufacturer, etc.

  4. Complete all spaces thoroughly to avoid unnecessary delay in concluding your claim.

Customer Name

 Home Telephone Office Telephone
New Address City State Zip Delivery Date
Old Address City State Zip Pick-up Date

IF EMPLOYER PAID FOR MOVE, NAME EMPLOYER  

DECLARED VALUE PROTECTION:   $.60/LB        LUMP SUM $         FULL VALUE

TAG/INV.

NO.

ITEM

Describe the item fully, including brand name, model & size

LOSS OR DAMAGE

List the nature and extent of damage. 

If missing, state MISSING.

ORIGINAL

COST

DATE

PURCHASED

(MM/YY)

AMOUNT

CLAIMED*

 

 

 

 

TOTAL

REMARKS:

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.

ICC 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

SIGNATURE

 

DATE