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File a Claim – Moved Between States
Dependable Relocation Services, Inc. – INTERSTATE CLAIM FORM
Corporate Headquarters 450 Airline Drive, Suite 100, Coppell, TX 75019 888-461-3737 Agent for United Van Lines, LLC, U.S. DOT No. 077949
ORDER FOR SERVICE NUMBER
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Customer First Name
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Customer Last Name
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Home Telephone
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Office Telephone
Email Address
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New Street Address
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New City
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New State
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Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
New Zip Code
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Delivery Date (MMDDYYYY)
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MM slash DD slash YYYY
Was shipment in warehouse?
Yes
No
Previous Street Address
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Previous City
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Previous State
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Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Previous Zip Code
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Pick Up Date
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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) if applicable
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 career within 9 Months from date of delivery.
Remarks
Signature of Claimant
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Today's Date
Month
Day
Year