United Van Lines, Inc. One United Drive Fenton, Missouri 63026

PRESENTATION OF CLAIM FOR LOSS AND DAMAGE INSTRUCTIONS FOR CLAIMANT 1. Print or type full particulars to the best of your knowledge. 2. Any articles found damaged must be kept available for inspection of your damages (including containers). 3. Contact the nearest United Van Lines Agent to arrange for inspection of your damages and assist in securing repair estimates. 4. If no UVL Agent is available, send this claim form to United Van Lines., #1 United Drive, Fenton, Missouri 63026. 5. In describing articles give as much information as possible such as color, kind of material, model numbers, trade name, manufacturer, etc. 6. Complete all spaces thoroughly to avoid unnecessary delay in concluding your claim.

PLEASE INSERT YOUR CARRIER NUMBER AND REFER TO IT IN ANY CORRESPONDENCE

Customer Name	Home Telephone	Office Telephone	WAS SHIPMENT IN WAREHOUSE? YES NO
New Address     City St ZIP		Delivery Date
Old Address     City St ZIP		Pick-Up Date
	EMPLOYED BY
DID EMPLOYER PAY FOR MOVE?     YES NO
WHAT WAS DECLARED VALUE PROTECTION?     $0.60¢/LB.    $1.25/LB.    Lump Sum $    Full Value Protection

						-	FOR HOME OFFICE USE ONLY
TAG/INV NO.	ITEM Describe the item fully, including Brand name, model and size	LOSS OR DAMAGE / List the nature and extent of damage if missing, state MISSING	ORIGINAL COST	MM/YY PURCHASED	AMT CLAIMED a. Repair Cost b. Replace Cost (SEE NOTE)	-	AGENT	C/S	REPAIRS
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*Note: Arrangements will be made to inspect the claimed item(s). ICC regulations require a specific or determinable amount must be provided for each item claimed. If repairs are required enter the reasonable estimate of the cost of repairs.				T O T A L:

I AM THE OWNER OF 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. ICCEGULATIONS REQUIRE THAT ANY CLAIM FOR LOSS, DAMAGE OR DELAY MUST BE SUBMITTED IN WRITING BY CLAIMANT WITHIN NINE (9) MONTHS FROM DATE OF DELIVERY.

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