← Back to Forms Household Goods Cargo Claim Form View Information Required for Claim You will need to provide: Bill of Lading and/or Warehouse Receipt Furniture Inspections (if applicable) Inventories and/or exceptions (if applicable) Step 1 of 4 - Reported By 0% Reported ByInsured / Moving Company(Required) Reported By(Required) Date of Loss(Required) MM slash DD slash YYYY ClaimantName of Claimant (Shipper)(Required) Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone(Required) Loss DetailsPer your Bill of Lading, your shipment was released at which of the following:(Required) $0.60 per pound per article Other, specific value. Specific Value(Required) Details of Loss(Required)Article DamagedDescription of DamageAmount Claimed Add RemoveUpload Additional Documentation Drop files here or Select files Max. file size: 100 MB. Upload any available additional documentation. (e.g. Bill of Lading or Warehouse Receipt, Furniture Inspections, and Inventories and/or exceptions) By signing below, I certify that all information made in this statement of claim and any attached documents are true and correct to the best of my knowledge and belief.Signature(Required)Email Address(Required)