Dd Form 1844 - List Of Property And Claims Analysis Chart
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1LIST O F PROPERTY A ND CLA IMS AN ALYSIS CHART
3.
PICK-UP DATE
1. NAME OF CLAIMANT (Last, First, Middle Initial)
(MMDDYY)
WHITE, John A.
031400
ITEMS 14 THROUGH 31 TO BE FILLED OUT BY CLAIMS OFFICE
4.
DELIVERY DATE
14. ORIGIN CONTRACTOR
17. 2ND CONTRACTOR
21. CLAIM NUMBER
22. NET WT/MAX CAR LIABLE
2. CLAIMANT'S INSURANCE COMPANY (If applicable)
(MMDDYY)
a. NAME
b. POLICY NO.
042500
None
N/A
5.
6.
7.
LOST OR DAMAGED ITEMS
8.
9. ORIGINAL
11. AMOUNT
15.
INVENTORY DATE
18.
EXCEPTION SHEET DATA
23. GBL NUMBER
24. LOT NUMBER
COST
CLAIMED
(MMDDYY)
(MMYYDD)
(Describe the item fully, including brand name,
a. REPAIR
model and size. List the nature and extent of
LINE
QTY
INV
COST
damage. If missing, state "MISSING.")
NO.
NO.
16.
19.
20.
25.
26.
27.
28. WARE-
29.
EXCEPTIONS
INV
EXCEPTIONS
AMOUNT
ADJUDICATOR'S
ITEM
HOUSE
CARRIER
10. MM/YY
b. (OR)
NO.
ALLOWED
REMARKS
WT
LIABI LITY
LIABI LITY
PURCHASED
REPL C OST
Sony 27" Color TV, model #A3456, S/N:
353.00
120.00
1
12345 (Electrical items w/ internal damage
1
253
must have an estimate of repair)
Picture not working correctly
05/96
Black Laquer Entertainment Center
289.00
2
156
Shelves broken in half and base cracked in
half
02/97
190.00
Box of clothing (Specify items on another
200.00
3
sheet of paper. Name brand clothing will
1
25
not be payed unless you can substantiate
for the items) Missing
97/99
190.00
Running Shoes
80.00
4
4
23
Missing
97/99
75.00
1 China Set (Claimants must specify the
95.00
5
amount of dishes that were damages or
1
76
broken)
4 plates of a set of 12 were broken
12/95
30.00
End Table (Claimant may get a loss of
65.00
15.00
6
vulue on items that have scratches or
1
96
gouges, for purposes that the item may still
be used for its purpose) Scratched
04/98
IDP CPU, Model #: S234, S/N:12345
850.00
60.00
7
(Internal damage to CPU's must submit a
1
251
computer repair form with the item)
Internal cooling fan won't work
08/99
Estimates for TV and CPU
8
1
60.00
12. REMARKS
13. TOTAL
13. TOTAL
13. THIRD
$
$
$
$
AMOUNT
AMOUNT
PARTY
740.00
CLAIMED
ALLOWED
LIABI LITY
DD FOR M 1844, FEB 89
1
1
Page
of
Pages
Previous editions may be used un til exhausted.
USAPPC V1.00
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