Action Moving Claim Form

Intrastate and Local Claim Form
for Action Moving Services, Inc.

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, as illustrated below:


Inventory No.	Description of article	Description of Damages	Did Action pack this item?	Estimated Weight	Original Cost	Date Acquired	Amount Claimed
123	Wood End Table	Scratch on top, nick on leg		12 lbs.	$195	1982	$45
130	Carton Dishes	Plate broken	Yes	40 lbs.	$25	1981	$25

3. If you are making a claim for lost items, please
a. Itemize contents of containers.
b. Include evidence of ownership for all items claimed as lost.
4. Please include copies of your order for service, bill of lading and inventories.
5. Complete part C of the form.

PART A
Your Name:
Origin:	city state
Destination:	city state
Loading Date:
Cartons Packed By:
Unpacked By:
Delivery Date:
Stored At:
Dates of Storage:

Amount of Valuation on Bill of Lading:	$

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:
	Email:
	Date:
	Street:
	City:
	State:
	Zip:
	Home Phone:
	Office Phone:
	Company:
	Position:

1-800-328-3803

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