Claim Form

Thank you for the confidence you displayed in allowing us to participate in your relocation. We sincerely regret that move was not to your complete satisfaction. We will do everything possible to correct this problem.

Please complete this form and submit it along with a copy of your bill of lading, and any documentation in support of your claim (Photos of Damage, Repair Estimates, Original Purchase Receipt, Etc.) directly to the clams department. Any omissions will delay processing.

**Important: PLEASE DO NOT MAKE any repairs prior to us documenting and rectifying your claim.

False or Fraudulent Claims

Any person who knowingly and with intent to defraud any insurance company or other person files a statement or claim containing any materially false information or conceals for the purpose of misleading information concerning any fact material there to, is committing a fraudulent insurance act, which is a crime and punishable by law.

* Date Of Claim:

* Date Of Move:

* Name of Claimant:

* Email:

* Home Phone:

Cell Phone:

Present Address:

* Address:

* City:

* State:

* Zip Code:

Moved From:

* Address:

* City:

* State:

* Zip Code:

Your claim is subject to the terms of and limited to the valuation coverage you authorized which is documented on the bill of lading. There are two (2) types of coverage.

*Please Check The Box
I have contracted for the following coverage:

* Please Check Box For Coverage You Have:
NY State Standard Valuation Coverage - 30cents per pound per article (basic coverage: Included at no additional cost.)
Actual Cash Value (ACV) Coverage - Depreciated Type (Additional Valuation - Premium Paid)

Please Note: Regarding containerized items - Long Island Moving and Storage, Inc. is not responsible for items packed by owner (shipper) "PBO's" unless such items were packed, unpacked and inspected by Long Island Moving and Storage, Inc. at an additional cost, they are not protected by any type of valuation coverage.

* How May Items Do You Wish To Claim?:
Choose Number From The Drop Down

Item 1 For Claim

Description:
List Type/Description of Item, Nature and Extent of Loss or Damage.

Weight of Item:

Original Cost of Item:

Acquired Date:

Depreciated Value At Time Of Loss:

Upload Damaged Item's Photos, Purchased Receipts, Repair Estimates, etc.:

Item 2 For Claim

Description:
List Type/Description of Item, Nature and Extent of Loss or Damage.

Weight of Item:

Original Cost of Item:

Acquired Date:

Depreciated Value At Time Of Loss:

Upload Damaged Item's Photos, Purchased Receipts, Repair Estimates, etc.:

Item 3 For Claim

Description:
List Type/Description of Item, Nature and Extent of Loss or Damage.

Weight of Item:

Original Cost of Item:

Acquired Date:

Depreciated Value At Time Of Loss:

Upload Damaged Item's Photos, Purchased Receipts, Repair Estimates, etc.:

Signature

The undersigned signer of the foregoing statement, hereby makes a solemn oath to the truth of statements contained herein. The undersigned understands that this is to be a complete and accurate loss of damage to be claimed in connection with the transporation described in the foregoing statement. In no way does this document imply guilt upon the mover or responsibility to reimburse until proper investigation has been rendered.

* Signature of Claimant First Name:

* Signature of Claimant Last Name:

* Date of Signature:

* Name of Notary First Name:

* Name of Notary Last Name:

Signature of Notary With Stamp:
Please Print and Scan

* State of:

* County of:

If your are unable to submit a scanned notary signature please fax or contact our office