Claim Form

We are very sorry for any damage that may have occurred during your move. To submit a claim, please enter your information below, and we will get in touch with you as soon as possible.
All fields marked with an asterisk (*) are required.

First Name:*

Last Name:*

Address:*

Apt/Suite#:

City:*

State:*

Zipcode:*

Phone Number:*

Work Phone Number:

Email Address:*

Name of Employer:

Order # / Bill of Lading #:*

Pickup Date:*

Delivery Date:*

Origin Address:*

Delivery Address:*

Was shipment in a warehouse?*
YesNo

Are you the owner of the goods in question?*
YesNo

Have all transportation/storage charges been paid?*
YesNo

Inventory #	Article Name	Description of Damage	Purchase Date	Purchase Price $	Claim Amount $
Inventory Number - 1	Article Name - 1	Description of Damage - 1	Purchase Date - 1	Purchase Price - 1	Claim Amount - 1
Inventory Number - 2	Article Name - 2	Description of Damage - 2	Purchase Date - 2	Purchase Price - 2	Claim Amount - 2
Inventory Number - 3	Article Name - 3	Description of Damage - 3	Purchase Date - 3	Purchase Price - 3	Claim Amount - 3
Inventory Number - 4	Article Name - 4	Description of Damage - 4	Purchase Date - 4	Purchase Price - 4	Claim Amount - 4
Inventory Number - 5	Article Name - 5	Description of Damage - 5	Purchase Date - 5	Purchase Price - 5	Claim Amount - 5
Inventory Number - 6	Article Name - 6	Description of Damage - 6	Purchase Date - 6	Purchase Price - 6	Claim Amount - 6
Inventory Number - 7	Article Name - 7	Description of Damage - 7	Purchase Date - 7	Purchase Price - 7	Claim Amount - 7
Inventory Number - 8	Article Name - 8	Description of Damage - 8	Purchase Date - 8	Purchase Price - 8	Claim Amount - 8

Customer Signature:*

Information provided is not sold or shared.