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IN CASE OF DELAY, OR IF CHARGES EXCEED ESTIMATE BY MORE THAN 10% |
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NOTIFY ___________________________________________________________________ |
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TO |
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Transportation FR |
OM |
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Origin/Destinatio |
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ADDRESS __________________________________TEL. __________________________ |
n Fee |
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Payment in Cash or Certified Check, Money Order, Traveler's Check or Cashier's Check |
Fuel Surcharge |
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BILLING INFORMATION |
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Containers, Packing & Unpacking |
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NAME |
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Storage-In-Transit at Loca |
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tion___________________________________ |
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Date In_____________ Date Out___________ |
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SIT Pickup |
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CITY & STATE |
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and Delivery |
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Extra |
Pickups or Deliveries No.____________ at ______________________ |
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ATTENTION OF |
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Extra |
Labor, Special Services or Waiting Time |
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Notice: Carrierʼs tariffs, by this reference, are made a part of the bill of lading and |
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may be inspected at carrierʼs facility, or, on request, carrier will furnish a copy of any |
Bu |
lky Articles |
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tariff provision containing carrierʼs rates, rules or charges governing the shipment. |
A |
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dditional Weight Additives |
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SPECIAL SERVICES |
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Advanced Ch |
arges |
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n EXPEDITED SERVICE ORDERED BY |
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Shuttle Ser |
vice |
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SHIPPER DELIVERED ON OR BEFORE _____________________ |
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Self-Storage/Mini-Warehouse Pickups |
or Deliveries |
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n SHIPMENT COMPLETELY OCCUPIED A __________ CU. FT. VEHICLE |
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Overtime Pickups or Deliveries |
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n EXCLUSIVE USE OF A_____________CU. FT. VEHICLE ORDERED |
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n SPACE RESERVATION |
CU. FT. ORDERED |
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Other Additional Services |
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n ____________________________ |
n _______________________ |
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NOTE: For shipments with origin/destination in |
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such |
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property to the customer by carrier. The sale price |
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FOR |
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CUSTOMER’S DECLARATION of VALUE : THIS IS A TARIF |
F LEVEL OF CARRIER LIABILITY - IT IS NOT INSURANCE |
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Minimum Weight or Volume Charge |
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OPTION 1 |
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- The Cost Estimate that you receive from your mover MUST INCL |
UDE Full (Replacement) Value Protec |
tion for the articles |
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Terms & Conditions for Payment of Total Charges |
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that are |
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Charges n |
Prepaid n C.O.D.n |
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of Full (Replacement) Value Protection shown below. Full (Replacement) Value Protection |
is the most comp |
rehensive plan available |
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to be paid Cash, Certified Check or Money Order |
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for |
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Maximum amount to be paid at time of delivery to obtain |
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1) |
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delivery of an estimated C.O.D. shipment |
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BALANCE DUE (30 Working Days, Credit Extended if Requested) |
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(Replacement) Value Protection, if you do not declare a higher replacement value on this form prior to the tim |
e of shipment, the value of your |
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Prepayment Collected By |
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goods will be deemed to be |
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minimum valuation for the ship- |
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ment of $6,000. Under this |
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reflecting the cost of providing |
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BALANCE DUE Á |
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this full value cargo liability prote |
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If you wish t |
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default |
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ction for your shipment. |
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declare a higher value |
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o |
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amounts, you must indicate that va |
lue here. |
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the valuation charge in your cost estimate. |
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The Total VALUE of my s |
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_______ (to be provided by the Customer) |
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hipment is: $ _____________________ |
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DELIVERY ACKNOWLEDGEMENT: SHIPMENT WAS RECEIVED IN APPARENT GOOD CONDI- |
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Dollar Estimate of the COST of your move at |
Full (Replacement) Value Protectio |
n: $ |
__________________ (to be provided by Carrier) |
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TION EXCEPT AS NOTED ON INVENTORY, AND SERVICES ORDERED WERE PERFORMED. |
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shipment. (if you |
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do not make a selection, the “No Deductible” level of FULL value |
protection that is included in yo |
ur cost estimate will apply): |
SIGNED |
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) initial |
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provided by Carrier) |
REC'D FOR STORAGE |
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CONSIGNEE |
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(WAREHOUSE) |
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I acknowl |
edge that for my sh |
ipment I have |
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included in the |
BY |
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PER |
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the “ |
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” broch |
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received a copy of |
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(WAREHOUSEMAN'S SIGNATURE) |
DATE |
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Your Rights and Responsibilities When You Move |
ure expl |
aining these provisions. |
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Declaration of Article(s) |
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--- OR --- |
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of Extraordinary (Unusual) Value |
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- |
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additional cost beyond the base |
I acknowledge that I have prepared and retained a copy of the |
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OPTION 2 |
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. Under this option, a claim for |
“Inventory of Items Valued in Excess of $100 Per Pound per Article” |
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rate; however it provides only minimal protection |
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of the individual article multiplied |
that are included in my shipment and that I have given a copy of this |
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$6.00 (10 pounds times 60 cents). |
Inventory to the mover’s representative. I also acknowledge that the |
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$ ________________ (to be provided by Carrier) |
mover’s liability for loss of or damage to any article valued in excess |
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Dollar Estimate of the COST of your move under the 60 cents option: |
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higher cost estimate provided (above) for |
of $100 per pound will be limited to $100 per pound for each pound |
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of such lost or damaged article(s) (based on actual article weight), not |
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must initial and sign on the lines below- |
to exceed the declared value of the entire shipment, unless I have |
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______________ (Customer’s Initials) |
specifically identified such articles for which a claim for loss or dam- |
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I acknowledge that for my shipment |
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for which I have received an estimate |
age may be made on the attached inventory. |
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I have |
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Move” brochure explaining these provisions. |
__________________________________________________ |
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Customer’s Signature X |
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____________________________________________Date____________________ |
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CUSTOMER’S SIGNATURE) |
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DATE |
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MILBURN PRINTING • |
800-999-6690 • www.milburnprinting.com |
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FORM # 875R/Rev. 4/12 |
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