Claim Form : Household/Corporate
Claim Form : Household/Corporate
Thank you for allowing Rose Moving & Storage to service your recent relocation. We regret if you found the handling of your shipment to be less than satisfactory.

For your convenience, we have provided an on-line version of our Claim Form to expedite the claim process. Please complete the claim form that follows and transmit it to us.

Receipt of your claim will be acknowledged and a claim number and an adjustor will be assigned. Your adjuster will review the claim and contact you, if necessary, with any further instructions.

Since all damaged items are subject to inspection, please do not proceed with any repairs, and do not dispose of any damaged items. A "Comments" section has been provided should you need to provide further explanation for any items or issues referenced in your claim.

If we can be of any further assistance, please contact us.
** Statement of Claim **
Customer Information

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 Rose customer, if different):
Your shipment's Registration #:
This number can be obtained from the upper right hand corner of your Bill of Lading.
Home Phone: () -
Business Phone - Extension: () - ext -
Your Cell Phone: () -
Your Fax Number: () -
Your e-Mail Address:
To use our Internet Claim Form, you must enter a valid e-Mail address where you can receive information regarding your claim. This is where your receipt & tracking number will be sent. Please double check your e-Mail and spelling after entering it into the box to the right!!
Moved To:
(Destination Address)
Address
City
State/Province Zip/Postal Code
Moved From:
(Origin Address)
Address
City
State/Province Zip/Postal Code
Present Address:
Enter your present address, city, state/province and zip/postal code. This address should be where you can be contacted for information about your claim.
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?
Indicate the appropriate circle if the charges for your move have or have not been paid.		 Yes No
Did your employer pay the charges?
Also indicate if your employer paid the freight charges.		 Yes No
Employed by:
Was your shipment stored in a warehouse?
Indicate if your shipment was or was not stored in a warehouse at origin (where you moved from) or at destination (where you moved to).
 Yes No
If 'YES', where?
Agent Name
City
State/Province
What type of valuation was your shipment moved under?
Please check the declared value of your shipment and whether it was released at a value of 60 cents per pound per article (U.S. and Canada), or if you selected Declared Value Protection (U.S. only) or the Extra Care Protection or Customer Transit Protection plan (U.S. and Canada), and which version: no deductible, $250 deductible, $500 deductible. This information is located in the lower left portion of your Bill of Lading.
Select One:
60 cents/lb. per article (U.S. and Canada)
Declared Value Protection (U.S. only)
Extra Care Protection/Customer Transit Protection - no deductible (U.S. and Canada)
Extra Care Protection - $250 deductible (U.S. only)
Extra Care Protection - $500 deductible (U.S. only)
Amount of Coverage:   $
Comments: