agent id: 1993i2249 Claims Management

MOVER CLAIM FORMS
STATEMENT OF CLAIM

Please complete all information

Please note: All property claimed damaged must be available

For inspection at the delivery address

Molloy Brothers Moving & Storage

185 Price Parkway

Farmingdale, New York, 11735

Claimant’s Name:
**Field is missing
Claimant’s Address:
**Field is missing
Order Number **Field is missing
Date of Pickup
**Field is missing
Date of Delivery:
**Field is missing
**Field is missing
Shipment Origin Address:
**Field is missing **Field is missing **Field is missing
Destination Origin Address:
**Field is missing **Field is missing **Field is missing
inv # ("na" if unavailable)
Description of Article
Nature & Extent of Damage
Approx Weight
Date of Purchase
Purchase Price
Claim Amount

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 knowledge and belief and constitutes my complete and entire claim. No material information has been withheld.

The value of my shipment was $Missing field

SELF ADJUSTMENT GUIDE
WOOD

Scratch $65.00

Nick/Chip $35.00

Gouge $60.00

Dent $35.00

Broken Leg $75.00

UPHOLSTERY

Mending $80.00

CLEANING

Chair $120.00

Sofa $150.00

Rug $130.00

APPLIANCES

Scratch $120.00

Dent $125.00

Handle $115.00

Claimant's Signature
Enter your name as your signature, verifing the infomation provided is accurate.
**Signature is missing


Email Address:
**Email is invalid or missing


After you submit your claim you will be able to submit photos of the damage.
IMPORTANT – PLEASE READ

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