Name: Daryl Flood Relocation
Address: 15833 Long Vista Drive, Suite 102, Austin, TX, 78728
Price range: $$

ORDER FOR SERVICE NUMBER*
Customer First Name*
Customer Last Name*
Home Telephone*
Office Telephone
Email Address*
New Street Address*
New City*
New State*
New Zip Code*
Delivery Date*
MM slash DD slash YYYY
Was shipment in warehouse?
- Yes
- No
Previous Street Address*
Previous City*
Previous State*
Previous Zip Code*
Pick Up Date*
MM slash DD slash YYYY
Did employer pay for move?
- Yes
- No
Employed By
What was declared value protection?
- 60/LB
- Full Value Protection
Deductible $
List of Claim Items
Inventory Number Article Weight Article Description Description of loss/damage Date of purchase/Age of item Cost to replace Amount Claimed Carton Damaged (Y/N)
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 my knowledge and brief and constitute my complete and entire claim. No material information has been withheld. U.S. DOT regulations require that any claim for loss, damage or delay must be submitted in writing by claimant and received by carrier within 9 Months from date of delivery.
Remarks
Signature of Claimant*
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Daryl Flood Relocation, Inc. – MMI Claim Form

Inventory Number	Article Weight	Article Description	Description of loss/damage	Date of purchase/Age of item	Cost to replace	Amount Claimed	Carton Damaged (Y/N)