Milburn Form 875R – Fill Out and Use This PDF

IN CASE OF DELAY, OR IF CHARGES EXCEED ESTIMATE BY MORE THAN 10%

NOTIFY ___________________________________________________________________

TO

Transportation FR

OM

Origin/Destinatio

ADDRESS __________________________________TEL. __________________________

n Fee

Payment in Cash or Certified Check, Money Order, Traveler's Check or Cashier's Check

Fuel Surcharge

BILLING INFORMATION

Containers, Packing & Unpacking

NAME

Storage-In-Transit at Loca

tion___________________________________

ADDRESS

Date In___

__________ Date Out___________

SIT Pickup

CITY & STATE

and Delivery

Extra P

______

ATTENTION OF

ickups or Deliveries No.____________ at ________________

Extra

Labor, Special Services or Waiting Time

Notice: Carrierʼs tariffs, by this reference, are made a part of the bill of lading and

may be inspected at carrierʼs facility, or, on request, carrier will furnish a copy of any

Bu

lky Articles

tariff provision containing carrierʼs rates, rules or charges governing the shipment.

A

dditional Weight Additives

SPECIAL SERVICES

Advanced Ch

arges

n EXPEDITED SERVICE ORDERED BY

Shuttle Ser

vice

SHIPPER DELIVERED ON OR BEFORE _____________________

Self-Storage/Mini-Warehouse Pickups

or Deliveries

n SHIPMENT COMPLETELY OCCUPIED A __________ CU. FT. VEHICLE

Overtime Pickups or Deliveries

n EXCLUSIVE USE OF A_____________CU. FT. VEHICLE ORDERED

n SPACE RESERVATION

CU. FT. ORDERED

Other Additional Services

n ____________________________

n _______________________

NOTE: For shipments with origin/destination in

such

property to the customer by carrier. The sale price

AGENT AND

Agt. Code

FULL SERVICE

CONTAINERS & PACKING $

UNPACKING $

SERVICE DATA

No.

DATE LOADED

CUSTOM SERVICE

CONTAINERS & PACKING

UNPACKING

AT RES.)

CARTON DESCRIPTION

QUANTITY

QUANTITY

BY

DISH PACKS

DATE LOADED

CARTONS

LESS THAN 3 CFT.

TOTAL

AT WHSE.)

BY

CARTONS

3 CFT.

 AND AND

AGENT

BOOKED

CARTONS

4.5

BY

ORIGIN

CARTONS

6

UNPACKING

PACKING

CONTAINERS

MATTRESS CTN., KING/QU. (EXCEEDING 54" X 75")

PACKED

CARTONS

6.5

BY

WARDROBE, CTN.

HAULER 1.

FROM

TO

CRIB MATTRESS CTN.

HAULER 2.

MATTRESS CTN., TWIN/TWIN LONG

MATTRESS CTN., DOUBLE (NOT EXCEEDING 54" X 75")

FROM

TO

UNPACKING

HEAVY DUTY

BY

DATE

OTHER

DELIVERED

DRIVER

TOTAL UNPACKING

$

FOR

CUSTOMER’S DECLARATION of VALUE : THIS IS A TARIF

F LEVEL OF CARRIER LIABILITY - IT IS NOT INSURANCE

Minimum Weight or Volume Charge

OPTION 1

- The Cost Estimate that you receive from your mover MUST INCL

UDE Full (Replacement) Value Protec

tion for the articles

Terms & Conditions for Payment of Total Charges

that are

Charges n

Prepaid n C.O.D.n

of Full (Replacement) Value Protection shown below. Full (Replacement) Value Protection

is the most comp

rehensive plan available

to be paid Cash, Certified Check or Money Order

for

Maximum amount to be paid at time of delivery to obtain

1)

delivery of an estimated C.O.D. shipment

BALANCE DUE (30 Working Days, Credit Extended if Requested)

(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

Prepayment Collected By

goods will be deemed to be

minimum valuation for the ship-

ment of $6,000. Under this

reflecting the cost of providing

BALANCE DUE Á

this full value cargo liability prote

If you wish t

default

ction for your shipment.

declare a higher value

o

amounts, you must indicate that va

lue here.

the valuation charge in your cost estimate.

The Total VALUE of my s

_______ (to be provided by the Customer)

hipment is: $ _____________________

DELIVERY ACKNOWLEDGEMENT: SHIPMENT WAS RECEIVED IN APPARENT GOOD CONDI-

Dollar Estimate of the COST of your move at

Full (Replacement) Value Protectio

n: $

__________________ (to be provided by Carrier)

TION EXCEPT AS NOTED ON INVENTORY, AND SERVICES ORDERED WERE PERFORMED.

shipment. (if you

do not make a selection, the “No Deductible” level of FULL value

protection that is included in yo

ur cost estimate will apply):

SIGNED

) initial

provided by Carrier)

REC'D FOR STORAGE

CONSIGNEE

(WAREHOUSE)

I acknowl

edge that for my sh

ipment I have

included in the

BY

PER

the “

” broch

received a copy of

(WAREHOUSEMAN'S SIGNATURE)

DATE

Your Rights and Responsibilities When You Move

ure expl

aining these provisions.

Declaration of Article(s)

--- OR ---

of Extraordinary (Unusual) Value

-

additional cost beyond the base

I acknowledge that I have prepared and retained a copy of the

OPTION 2

. Under this option, a claim for

“Inventory of Items Valued in Excess of $100 Per Pound per Article”

rate; however it provides only minimal protection

of the individual article multiplied

that are included in my shipment and that I have given a copy of this

$6.00 (10 pounds times 60 cents).

Inventory to the mover’s representative. I also acknowledge that the

$ ________________ (to be provided by Carrier)

mover’s liability for loss of or damage to any article valued in excess

Dollar Estimate of the COST of your move under the 60 cents option:

higher cost estimate provided (above) for

of $100 per pound will be limited to $100 per pound for each pound

of such lost or damaged article(s) (based on actual article weight), not

must initial and sign on the lines below-

to exceed the declared value of the entire shipment, unless I have

______________ (Customer’s Initials)

specifically identified such articles for which a claim for loss or dam-

I acknowledge that for my shipment

for which I have received an estimate

age may be made on the attached inventory.

I have

Move” brochure explaining these provisions.

__________________________________________________

Customer’s Signature X ____________________________________________Date____________________

CUSTOMER’S SIGNATURE)

DATE

MILBURN PRINTING • 800-999-6690 • www.milburnprinting.com

FORM # 875R/Rev. 4/12