Claims

To fill out this Statement of Claim form, you will need to reference your copy of the following items:

a. Household Goods Carrier's Bill of Lading and Freight Bill.
b. Household Goods Descriptive Inventory.

In all cases, keep damaged articles (including shipping containers) for inspection. Arrangements will be made to inspect and estimate damage to the articles you have claimed.

* Your name (and the name of the Mayflower customer, if different):

* Your Order Number:

* Home Phone:

( ) -

Business Phone - Extension:

( ) - ext.

Your Fax Number:

( ) -

Your Email Address:

Moved To:
(Destination Address)

Address
City
State/Province		Zip/Postal Code

Moved From:
(Origin Address)

Address
City
State/Province		Zip/Postal Code

Present Address:
Click if same as "Moved To:" address above.

Address
City
State/Province		Zip/Postal Code

The date your items were loaded onto the truck:

(mm/dd/yyyy)

The date your items were delivered:

(mm/dd/yyyy)

Have transportation charges been paid in full?

Yes No

Did your employer pay the charges?

Yes No

Employed by:

Was your shipment stored in a warehouse?

Yes No

If 'YES', where?

Agent Name
City
State/Province

What type of valuation was your shipment moved under?

Select One:

60 cents/lb. per article (U.S. and Canada)
Declared Value Protection (U.S. only)
Full Value Coverage/Customer Transit Protection - no deductible (U.S. and Canada)
Full Value Coverage - $250 deductible (U.S. only)
Full Value Coverage - $500 deductible (U.S. only)

Amount of Coverage: $

Comments
(300 Characters max)

When you are done with the Claim Damages phase of the form, click on the "Proceed to the next step" button.