Pacific West Moving LLC

5204 River Rd. Bethesda, MD 20816

(301) 466-7226 Fax (301) 560-4975

www.paxwest.com

PRESENTATION OF CLAIM FOR LOSS AND DAMAGE

INSTRUCTIONS TO CLAIMANT

 Invoice #

1. Print or Type Full Particulars to the best of your knowledge.

2. Any articles found damaged must be kept available for inspection (including containers)

3. In describing articles give as much information as possible: color, material, model #, trade/name, mfg., etc.

4. Complete all spaces thoroughly to avoid unnecessary delay in concluding your claim.
Customer Name Home Telephone Office Telephone
New Address City State Zip Email Address
Old Address City State Zip Service Date:
 

DID EMPLOYER PAY FOR MOVE?

 YES NO Employed By:  Home Office Address:
WHAT WAS DECLARED VALUE PROTECTION?

$.60/Lb.

  

$1.25/Lb.

  

LUMP SUM

   FULL VALUE PROTECTION  

TAG/INV.

NO.

ITEM

Describe item, including, brand, model & size.

LOSS OR DAMAGE

Nature and extent of damage.

If MISSING, state MISSING.

ORIGINAL

 COST

 MM/YY PURCHASED AMOUNT CLAIMED FOR HOME OFFICE USE ONLY
AGENT C/S REPAIRS
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 

Note: Arrangements will be made to inspect the claimed item(s). ICC regulations require a specified or determinable amount must be provided for each item claimed.

TOTAL:

Enter Remarks Below
 
 
 
 
 

I am the owner of the property described. I did not cause or contribute to the damage set forth herein. All statements made in this statement of claim/attached documents are true & correct to the best of my knowledge and belief, and constitute my complete and entire claim.  No material information has been withheld.Insurance regulations require damage to be reported on site. Once Pacific West Moving LLC leaves the site the liability for damage is no longer available. Any and all requests must be made on site.
Signature of Claimant:   Date: