CLAIM FORM INSTRUCTIONS: Complete all sections of the form as completely as possible. If all sections are not complete, it will slow the process. Upload photos of said damage. Provide purchase receipts, if available. Please DO NOT, have any repairs completed or replace items, until we have had the opportunity to inspect them (or your claim will be null and void). We do not pay for estimates performed by someone other than our preferred vendors. Keep in mind, claims must be filed within 30 days of move date. Freight charges must be paid in full, prior to opening a claim. We regret any damage/loss that may have occurred and hope to resolve your claim as quickly and as fairly as possible. Please note that most claims are acknowledged within thirty days of receipt. However, in some cases, claims may not be completely processed within this time frame. Thank you!Full Name*(First, Last) Today's Date* MM slash DD slash YYYY Date of Move* MM slash DD slash YYYY Primary Phone #:*Secondary Phone #:Email Address:* Current Address:* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Total value of all goods shipped on this bill of lading: in $* Total replacement value of goods shipped: in $* Did you purchase upgraded valuation protection through Road Scholars?* YES NO If yes, which deductible option did you choose: in $* If no, did you release your shipment at .60 cents per pound?* YES NO Has notice of loss been reported to agent of Road Scholars?* YES NO If yes, name of agent:* Date reported:* MM slash DD slash YYYY What date was damage or loss discovered:* MM slash DD slash YYYY By Whom Discovered:* Are you claiming articles packed in a box? If so, please provide information below:* Yes No IF CLAIM IS FOR BREAKAGE OR LOSS TO ITEMS PACKED IN CONTAINERS, PLEASE PROVIDE US WITH THE FOLLOWING INFORMATION:Who packed:* By whom unpacked:* Date unpacked:* MM slash DD slash YYYY Was packing container damaged?* YES NO If yes, in what manner was box/container damaged?* DETAILED STATEMENT SHOWING HOW AMOUNT CLAIMED IS DETERMINED*Item #Full Detailed Description of ItemNature and Extent of DamageDate Item AcquiredOriginal Cost (in $)Weight of Item (in LBS)Amount Claim/ Repair (in $) Was there property damage?*(Examples of property damage: drywall, stairwell, landscaping, flooring. NOT FURNISHINGS OR BOXED ITEMS.) Yes No DETAILED CLAIM STATEMENT*Item/Area DamagedAddress of DamageNature and Extent of DamageAmount Claim or Repair Requested (in $) Photos of Damage (Multiple Files Can Be Uploaded)(It is very important to provide photos.) Drop files here or Select files Max. file size: 100 MB. REMARKS:Acknowledgment of above Claim Form* Yes Claimant agrees to all terms of this agreement and acknowledges receipt of a copy of this agreement. I certify that the above facts are true to the best of my knowledge and belief. I understand that Road Scholars Moving & Storage may open an investigation on the claim submitted above, requesting: pictures, receipts, further supporting documentation, or inspection of item(s). I further acknowledge that this is my full and final claim and that I may not make additional claims after this is submitted.HiddenSIGNATURE OF CLAIMANTSign your name hereSignature of Claimaint* Please type your full nameCAPTCHA Δ
