BAILEY'S MOVING and STORAGE

Statement of Claim
Customer Information

To fill out this Statement of Claim form, you will need to reference your copy of the following items:

a. Household Goods Carrier's Bill of Lading and Freight Bill.
b. Household Goods Descriptive Inventory.

In all cases, keep damaged articles (including shipping containers) for inspection. Arrangements will be made to inspect and estimate damage to the articles you have claimed.

Please be advised that for interstate (long distance) moves, you only have NINE MONTHS from the date of delivery to complete and send this form to our office. And for local/intrastate/perm storage moves, you only have ninety days to notify us of a claim and FOUR MONTHS from the date of delivery to complete and send this form to our office. The carrier must receive the claim form within the stated filing period

Name of the Allied customer:

Shipment's 5-digit (Canada) or 6-digit (U.S.)
Registration Number: Or: registration number for Intra state/Perm
Storage/Local

Home Phone: () -

Business Phone: () - ext.

Fax Number: () -

Email Address:

Moved To:
(Destination Address)

Address

City

State/Province Zip/Postal Code

Moved From:
(Origin Address)

Address

City

State/Province Zip/Postal Code

Present Address:

Address

City

State/Province Zip/Postal Code

Date items were loaded onto truck: (mm/dd/yyyy)

Date items were delivered: (mm/dd/yyyy)

Have transportation charges been paid in full? Yes No

Did your employer pay charges? Yes No

Employed by:

Was the shipment stored in a warehouse? Yes No

If 'YES', where?

Agent Name

City

State/Province

What type of valuation was shipment moved under?
Select One:

60 cents/lb. per article (U.S. and Canada)
Declared Value Protection (U.S. only)
Extra Care Protection/Customer Transit Protection - no deductible (U.S. and Canada)
Extra Care Protection - $250 deductible (U.S. only)
Extra Care Protection - $500 deductible (U.S. only)
Amount of Coverage: $

Please enter the information regarding the item you wish to claim. To be processed correctly, the claimed item must include an Inventory Item number OR if your claim resulted from a local or Intra-state move, there may not be any inventory number associated with your claim. If the Inventory Item number is not included, no action will be taken.
NOTE: If the item is repairable but you will accept a nominal cash allowance instead of repairs, enter the amount you are requesting. If repairs are required, please click the "repair" box. Arrangements will be made to inspect the claimed item.

When you are ready to add another item to the Claim Form,
please click on the 'Click Here to Add Another Item' button.