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Verified Statement of Claim for Lost or Damaged Goods

We are sorry you have found it necessary to report a claim. Roadway Vanlines attempts to settle all claims in an equitable and timely manner. We appreciate your cooperation in filling out the form. Upon receipt of the form, a file will be established and assigned to an adjuster.

General Instructions: 

A. Please retain the damaged articles, including shipping cartons. These items must be available for inspection.

B. Time limit for filing claim is 9 months from date of delivery or conversion to permanent storage. The 9-month claim filing period does not apply to government, military and some national account contracts. Contact your booking agent, transportation management office or move coordinator for specific claim filing information.

C. Please have shipping documents available at time of inspection.

D. Transportation charges must be paid prior to claim settlement.

You signed for your valuation decision on move day on the bill of lading. An example of the difference between the two valuation options are: if a 10 lb chair were to sustain damage during the relocation process, coverage would be applied as follows: Option 1: Road Way Van Lines would be obligated to repair, replace, or provide an appropriate cash settlement after application of the deductible. Option 2: Road Way Van Lines would be liable up to $6.00 (60 cents x 10lbs). *Note: option 2 is $1/lb. only in the state of New Jersey. Regardless of any previous written or oral communications, you must include on this form all articles that you claim are either lost or damaged as well as any documents that would support your claim in order to receive compensatory consideration. Do not destroy, repair or dispose of any claimed item until full settlement has been completed.

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Click or drag a file to this area to upload.
The undersigned does hereby swear or affirm that all entries made in this Statement of Claim and contained in the attached supporting documentation are true and correct to the best of my knowledge and belief and constitute my complete and entire claim growing out of or in any way connected with the transportation or storage of my possessions. The undersigned does further swear or affirm that there have been no material facts relative to this claim that have either been withheld or misrepresented. The undersigned does hereby agree that if it is determined by Road Way Van Lines, that any of the above information or supporting documentation is false, or that material facts have been withheld, then this shall justify the denial of my claim by Road Way Van Lines.
In making this claim, you must be prepared to justify the value you have placed on the lost or damaged articles. Remit any documents which would be required in support of your claim. This form must be signed by the claimant who is the owner of all items claimed to be lost or damaged.
Click or drag files to this area to upload. You can upload up to 5 files.

Helpful Hints: 

A. The ORDER FOR SERVICE NUMBER must be referenced on claim form and any subsequent correspondence or inquiries. If not already entered on the claim form, this number can be found at the top right hand corner of the Bill of Lading. This number also appears on the top right hand corner of the Order for Service.

B. Complete top portion of form thoroughly. Include zip codes with addresses and area codes with telephone number. Please give us the phone numbers where you can be reached during normal business hours.

C. Complete all columns for articles claimed:

1. Not providing Inventory Numbers may delay the processing of your claim.

2. Give a brief description of article claimed including make and model number if applicable, (COFFEE TABLE, TV-XYZ, MODEL 123).

3. Describe the extent, location and nature of damage, (SCRATCH TOP RIGHT EDGE, OR LEFT REAR LEG BROKEN).

4. Indicate the article’s replacement cost today for same, or similar articles.

5. Enter the amount you are claiming in settlement. The CLAIM FORM is not complete without this amount.

6. If the claimed item was packed, please indicate whether the carton was damaged by marking YES or NO in the appropriate column. This information is important since we allocate responsibility to the party responsible for the reported damage.

7. A claim process may take up to 120 days.

D. If additional space is required, please be sure attached pages include the same information requested on this form.

E. The claim must be signed and dated. Failure to sign will result in the form being returned for signature.

F. Be sure all unpacking has be accomplished, and all items checked, before submitting claim.

G. Do not have any items repaired unless we advise you to do so.

 

Sample: 

1 2 3 4 5 6
Inventory number Article weight Article Description Description of loss / damage Date of purchase/ age of item Cost to replace Amount claimed Carton Damaged? Yes or No
38 40 lbs End Table SCRATCHED TOP 4 YRS. $275 $50 N/A
15 30 lbs Glass Bowl BROKEN 8 MTH. $22.50 $22.50 No

 

Minimum Filing Requirements: 

Federal regulations establish the minimum filing requirements as a “communication in writing from a claimant filed with a proper carrier within the time limits specified in the bill of lading or contract of carriage for transportation, and (i) containing facts sufficient to identify the baggage or shipment (or shipments) of property involved, (ii) asserting liability for alleged loss, damage, injury or delay, and (iii) making a claim for the payment of a specified or determinable amount of money, shall be considered as sufficient compliance with the provisions for filling claims embraced in the bill of lading or other contract of carriage.”

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