Instructions to Claimant:
- Fill in full particulars to the best of your knowledge.
- Any articles found damaged must be kept available for inspection (including containers). Do not complete any repairs.
- In describing articles give as much information as possible such as color, kind of material, model numbers, trade/name, manufacturer, etc.
- Complete all spaces thoroughly to avoid unnecessary delay in concluding your claim.
- Submit form to Chipman Adjusting Services.
Alert — This claim will be reported to the national household goods claim registry.
BY SUBMITTING THIS FORM, I CERTIFY THAT 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.