Claim_Form-Transit

							                                                                                             Certificate No: __________
                                                   CLAIM FORM
                                                TRANSIT DAMAGES
                                             (Please answer all questions below)

Name: __________________________________________________________________________________________

Address: ________________________________________________________________________________________

City: _______________________ State/Province: ________________________Country: _______________________

Zip/Post Code _______________________________Residence Telephone: __________________________________

Business Telephone: _____________________Facsimile: ______________________Date of Delivery: ____________

Describe the condition of the goods at the time of delivery. Comment on any incident that may have caused the

damages during this move. __________________________________________________________________________

_______________________________________________________________________________________________

________________________________________________________________________________________________

Packing                                                                                         Cost to
  List
              Item Damaged                  Description of Damages                 Insured   Repair/Cost to   Amount
  No.
                                                                                    Value      Replace        Claimed




                                                                           Total Amount of Claim: _______________

I/We certify that the statements contained herein are correct and truthful.

______________________________________________________________________________________
Signature                                                        Date

                                              Return Claim Form to:

Movers Risk Services LLC                                         Catherine Gutberlet
RD 2 Box 271A                                                          Telephone Number: 717-428-9387
Seven Valleys, PA 17360 USA                                            Fax Number: 717-428-9528