Corrigan Moving Systems

23923 Research Drive

Farmington Hills, MI 48335

248-471-4000 Fax 248-471-3746

800- Corrigan (267-7422)

PRESENTATION OF CLAIM FOR LOSS AND DAMAGE

INSTRUCTIONS TO CLAIMANT

Carrier Order #

1. Print or Type Full Particulars to the best of your knowledge.

2. Any articles found damaged must be kept available for inspection (including containers)

3. In describing articles give as much information as possible: color, material, model #, trade/name, mfg., etc.

4. Complete all spaces thoroughly to avoid unnecessary delay in concluding your claim.

Customer Name	Home Telephone			Office Telephone

New Address	City	State	Zip	Email Address

Old Address	City	State	Zip	Delivery Date:
				Pick Up Date :

WAS SHIPMENT IN WAREHOUSE?

YES

If yes, where? AGENT NAME

City

State

DID EMPLOYER PAY FOR MOVE?

YES

Employed By:

Home Office Address:

WHAT WAS DECLARED VALUE PROTECTION?

$.60/Lb.

$1.25/Lb.

LUMP SUM

FULL VALUE PROTECTION

TAG/INV.

NO.

ITEM

Describe item, including, brand, model & size.

LOSS OR DAMAGE

Nature and extent of damage.

If MISSING, state MISSING.

ORIGINAL

COST

MM/YY PURCHASED

AMOUNT CLAIMED

FOR HOME OFFICE USE ONLY

AGENT

C/S

REPAIRS

Note: Arrangements will be made to inspect the claimed item(s). ICC regulations require a specified or determinable amount must be provided for each item claimed.

TOTAL:

Enter Remarks Below

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/attached documents are true & correct to the best of my knowledge and belief, and constitute my complete and entire claim. No material information has been withheld. ICC Reg require claims be submitted in writing by claimant and received by carrier within 9 months from date of delivery.

Signature of Claimant:

Date: