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File a Claim – Moved Within Texas
Dependable Relocation Services, Inc. – INTRASTATE CLAIM FORM
Corporate Headquarters 450 Airline Drive, Suite 100, Coppell, TX 75019 888-461-3737 TxDMV #006779291C
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
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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
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)
TxDMV regulations require that any claim be submitted in writing and received by carrier within 90 days from delivery of the shipment to the final destination or after a reasonable time for delivery has elapsed in the case of failure to make delivery.
Remarks
Signature of Claimant
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Typing your name below will serve as an electronic signature
Today's Date
Month
Day
Year