Claim Form

Load Date*

Delivery Date*

Origin Address*

Street Address Address Line 2 City State ZIP Code

Weight*

Coverage*

Name Address*

Street Address Address Line 2 City State ZIP Code

Name Address of Moving Company*

Street Address Address Line 2 City State ZIP Code

List*

Inventory Item #	Article (Describe in Detail)	Nature of Claim (If Damage, Describe Extent)	Approx. Weight	Purchased Mo – Yr.	Cost	Amount Claimed

It is understood that losses from an interstate shipment may be reported to the F.B.I. which has investigative jurisdiction under Federal Laws regarding interstate or Foreign Commerce.

The actual cash value of shipment was:*

I am the owner of the property described. I did not cause or contribute to the damage set forth herein.

NY Fraud Warning: Any person who knowlingly, and with intent to injure, defraud or deceive and insurance company or other person files a statement of claim containing and materially false information, or conceals for the purpose of misleading, information concerning any fact material therto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.*

I certify that I have read and agree to all fraud warnings contained in this form and that all statements made in this statement of claim, and any attached documents are true and correct to the best of my knowledge and belief. No material information has been withheld.

Customer's Signature*

Date*

Home Phone #*

Business Phone #

Customer's Name*

Customer's Email Address*

Untitled*

I have reviewed the instructions and fraud warning.

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