Daryl Flood Relocation, Inc. – Phillips66 Claim Form Corporate Headquarters 450 Airline Drive, Suite 100, Coppell, TX 75019 800-325-9340 Agent for Mayflower Transit, LLC, U.S. DOT No.125563 ORDER FOR SERVICE NUMBER* Customer First Name* Customer Last Name* Home Telephone*Office TelephoneEmail Address* New Street Address* New City* New State*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificNew Zip Code* Delivery Date* MM slash DD slash YYYY Was shipment in warehouse? Yes No Previous Street Address* Previous City* Previous State*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificPrevious Zip Code* Pick Up Date* MM slash DD slash YYYY List of Claim ItemsInventory NumberArticle DescriptionDescription of loss/damageDate of purchase/Age of itemCost to replaceAmount Claimed Your employer requires that any claim be submitted in writing and received by carrier within 90 Days from delivery of shipment to the final destination or after a reasonable time for delivery has elapsed in the case of failure to make delivery.RemarksSignature of Claimant*Typing your name below will serve as an electronic signature Today's Date Month Day Year Δ
