Claims Form

Name

Date of filling claim

Reason for claim

Loss Damage Both

Address

Phone

Shipment Info:

Move order / Bill of loading #

Name and address of shipper

Same as above Other:

Name

Address

Shipment loading date

Shipment delivery date

Moving from:

Address

Moving to:

Address

Packed Items:

Shipment was temporarily held in storage?

No In Origin In Destination

Items packed by:

Items unpacked by:

Items unpacked:

When was damage/shortage discovered:

Discovered by:

Claim Items:

Item Name

Item Weight

Purchase Date

Purchase Price ($)

Value at time of loss ($)

Amount claimed ($)

Description of Damage

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Insurance:

Insurance with an outside carrier

I have insurance with an outside carrier I do not have insurance with an outside carrier

Insurance carrier

MovingInsurance.com Baker International Other

Insurance Carrier Name

Date of submission

Sign your claim

By checking this box, I am electronically signing my application

Signature

Claims Form

Shipment Info:

Moving from:

Moving to:

Packed Items:

Claim Items:

Insurance:

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