I moved within Texas I moved within Texas Daryl Flood Relocation, Inc. Corporate Headquarters 450 Airline Drive, Suite 100, Coppell, TX 75019 800-325-9340 TxDMV #006779291C Intrastate Claim Form Order for service number Customer First Name Customer Last Name Home Telephone Office Telephone Email Address New Address City State Zip Code Delivery Date Old Address City State Zip Code Pickup Date Was shipment in warehouse? Yes No Did employer pay for move? Yes No Employed By What was declared value protection? 60/LB Full value Protection Deductible $ 1 Inventory Number 2 Article Weight 3 Article Description 4 Description of loss/damage 5 Date of purchase/Age of item 6 Cost to replace 7 Amount claimed 8 Carton damaged (Yes or No) Home office use only C/S $ or R=repair Expl. Resp. Party Select Yes No NA Select Yes No NA Select Yes No NA Select Yes No NA Select Yes No NA Select Yes No NA Select Yes No NA Select Yes No NA Select Yes No NA Select Yes No NA Select Yes No NA Add More 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. Signature of Claimant Typing your name above will serve as an electronic signature Date Remarks
