ARBITRATION QUESTIONNAIRE

Moving Authority Household Goods Arbitration Program
Shipper/Claimant Questionnaire
Shipper/Claimant's Current Contact Information
!
This form is only for people who have already filled out a claim form.
If you submit this form and there is not a corresponding claim that has been filed beforehand, Moving Authority will not accept it.

Shipper/Claimant's Name:

Phone

Email

Mailing Address

Suite No.

Zip

City

State

Preferred method of contact

Best time to reach you

Moving Company Information (NOT Local Agent)

Name

Phone

Address

Suite No.

Zip

City

State

Contact person

#DOT

This form is for customers that have moved with moving companies and the form should be filled out completely below by the consumer that would like to initiate arbitration with the moving company that they hired.

Move Covereage:

High Value items:

Carrier Provided Storage:

Shipment Delivered To:

Who Packed Items:

Damage Noted During Delivery:

Did you fill out a claim form:

Reason for arbitration:


Shipper/Claiman Signature:

Date