Claim Form

Statement of Claim: Please use this form to register a claim for loss or damage to items transported intrastate and local by Action Moving Services.

Instructions:
1. Complete part A of the form with all available background information.
2. Identify your lost/damaged items accurately and completely in part B of the form, noting the inventory number, descriptions of the item and damage, and the item's weight, cost, date acquired and the amount you are claiming.
3. If you are making a claim for lost items, please itemize contents of containers and include evidence of ownership for all items claimed as lost.
4. Please include copies of your oder for service, bill of lading and inventories.
5. Complete part C of the form.
Part A
Bill of Lading Number:
Name:
First Last
Origin:
Destination:
Loading Date:
Date Format: MM slash DD slash YYYY
Stored At:
Amount of Valuation on Bill of Lading:
Part B
Part B
Inventory No. Description of article Description of Damages Did Action pack this item? Estimated Weight Original Cost Date Acquired Amount Claimed
Part C
The information contained in this loss/damage claim is true and correct to the best of my knowledge and belief, and constitutes my complete and entire claim for loss/damage.
- Yes, I agree
Current information:
Name:
First Last
Email:
Date:
Date Format: MM slash DD slash YYYY
Address:
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone:
Day Phone:
Company:
Position:
Untitled

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Inventory No.	Description of article	Description of Damages	Did Action pack this item?	Estimated Weight	Original Cost	Date Acquired	Amount Claimed