STANDARD PROOF OF LOSS AND DAMAGE CLAIMS UNDER UNIFORM HOUSEHOLD GOODS BILL OF LANDING Loss & Damage Claims Form Date of Filing Claim Claimant's Number Carrier's Number Claimant Information Full Name * Street Address City Zip Code State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Did You Purchase Full Replacement Value? * Yes No Description Description of Shipment Date shipment was loaded Moving from To Shipment Stored? Yes No If claim is for breakage or shortage to items packed in containers give following information: By whom packed By whom unpacked Date unpacked When was the damage discovered By whom discovered Claimed Statement Inventory Number (If applicable) Weight Acquired Date Original Cost Value of Loss Amount Claimed Describe Damage Claimed Statement Inventory Number (If applicable) Weight Acquired Date Original Cost Value of Loss Amount Claimed Describe Damage Claimed Statement Inventory Number (If applicable) Weight Acquired Date Original Cost Value of Loss Amount Claimed Describe Damage plus1 Add minus1 Remove THE FOLLOWING DOCUMENT IS SUBMITTED IN SUPPORT OF CLAIM A Repairman's estimate of cost of repair REMARKS The undersigned, signer of the foregoing statement, hereby makes a solemn oath to the truth of the statements contained herein, and exhibits attached hereto. Signature signature keyboard Clear If you are human, leave this field blank. Submit
