Presentation of Claim for Loss and Damage

Instructions to Claimant

  1. Fill in full particulars to the best of your knowledge.
  2. Any articles found damaged must be kept available for inspection (including containers). Do not complete any repairs.
  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.
  5. Submit form to Chipman Adjusting Services.

Alert – This claim will be reported to the national household goods claim registry.

PLEASE INSERT YOUR CARRIER REF. NUMBER AND REFER TO IT IN ANY CORRESPONDENCE:
Customer Name:            Home Telephone:             Office Telephone:            Email Address:  
     
New Address:   City:   State:            Zip:   Delivery Date (mm/dd/yy):
       
Old Address:   City:   State:   Zip:   Pick-up Date (mm/dd/yy):
       

WAS SHIPMENT IN WAREHOUSE?    NO     YES
DID EMPLOYER PAY FOR MOVE?    NO     YES    EMPLOYED BY:

WHAT WAS DECLARED VALUE PROTECTION?  
60¢/LB. $1.25/LB. LUMP SUM  ($ ) FULL VALUE PROTECTION  ($ ) DEDUCTIBLE  ($ )

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)		 AMT
CLAIMED*
*NOTE: Regulations require an inventory # and a specified amount be provided for each item claimed. If repairs are claimed enter the reasonable estimate of the cost of repairs. TOTAL:

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. 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.

    
REMARKS:
SIGNATURE OF CLAIMANT (Type your name here): DATE (MM/DD/YY):