Scobey Moving and Storage Claim Statement

Residential

Office Moving

International

Residential

Office Moving

Trade shows/
Exhibits

Household Goods Storage

Commercial Warehouse Solutions

Overview

History

Please ensure that all required (*) fields are completely filled in before submitting.

Company Information.

Scobey Moving and Storage
c/o PM Solutions
27818 N 130th Glen
Peoria, AZ 85383

Toll: 866 217 7644
Tel: 623 533 5724
Fax: 623 533 5728
pmsolutions@cox.net

Customer Information

Customer Address

Customer Contact

Shipment Information


* Was Shipment in Storage:		If Yes, Facility and Location:
Yes	No

* Claim Information (all known information)

Valuation Declared $.60 lb/article		ECP Deductable
DVP $1.25lb lump sum		ECP No Deductable
Did Employer Pay for Move:		If Yes, name of Employer:
Yes	No

Because of the nature of your claim we request that you not discard any of your packing materials or items being claimed until instructed by the claims adjuster that it is okay to do so. Disposing of these items prior to inspection will prohibit us from conducting a thorough claim investigation and could result in your claim being denied.

comments

Item No.	Desc. of Article	Missing or Damaged Desc.	Item Weight (lbs)	Where & When purchased (new or used)	Original Cost	Cost to Replace	Amount Claimed

	Please type your name below; This will be your electronic signature. (date format is mm/dd/yyyy)
		* Date:
	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 and any attached documents are true and correct to the best of my knowledge and belief, and constitute my complete and entire claim. No material information has been withheld. DOT regulations require that any claim for loss, damage or delay must be submitted in writing by claimant and received by carrier within 9 months from date of delivery (Texas local or intrastate move claims must be filed within 90 days from date of delivery).

Please complete this form and submit as many times as necessary for additional items.