Form MCSA-5846 Household Goods Motor Carrier Quarterly Report

OMB NO: 2126-0025
Expiration Date:

A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a collection
of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a current valid OMB Control Number. The
OMB Control Number for this information collection is 2126-0025. Public reporting for this collection of information is estimated to be approximately two hours per
response, including the time for reviewing instructions, gathering the data needed, and completing and reviewing the collection of information. All responses to this
collection of information are mandatory. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for
reducing this burden to: Information Collection Clearance Officer, Federal Motor Carrier Safety Administration, MC-RRA, Washington, D.C. 20590.

U.S. Department of Transportation
Federal Motor Carrier
Safety Administration

HOUSEHOLD GOODS MOTOR CARRIER QUARTERLY REPORT

Submission Date: ___________
Check here if this is an amended report
Company Name: __________________________________
Company Address:
_________________________________________________________________________________________
(Street Name and Number)

__________________________________________________________________________________________
(City)

(State)

(Zip)

Individual Point of Contact: ______________________
__________________________________________________________________________________________
(Phone)

(Fax)

________________________

______________________

(USDOT#)

Reporting Period: Year: ____

(Email)

(MC#)

Quarter:

1st

2nd

3rd

4th

Summary of Complaint and Claim Information for the Reporting Period:
1. Number of shipments that originate and are delivered for individual shippers during the reporting period:
______
2. Number of oral and written complaints in these general categories that consumers lodged against the
company:
A. Rates or Charges ______
B. Service ______
C. Loss and Damage ______
D. How Claims are Handled ______ E. Other ______
3. Number of claims filed with you for loss and damage in excess of $500: ____
4. Number of claims for loss and damage in excess of $500 settled during the reporting period: ______
5. Number of claims for loss and damage in excess of $500 declined in the reporting period: ______
6. Number of claims for loss and damage in excess of $500 pending at the close of the reporting period: ______

Form MCSA-5846 (Rev. Jan 2008)