Customer Information

Title

Name*

Email*

Registration #*

Home Phone Number*

Work Phone number

Work Fax Number

Where did you move to?

Address*

City*

State*

Zip Code*

Where did you move from?

Address*

City*

State*

Zip Code*

Is your present address different than the address you moved to?

Yes

HTML BlockIf "yes", please provide present address below.

HTML BlockPresent Address

Address

City

State

Zip code

Country

Additional Information

Date items were loaded onto truck

Date items were delivered

Is this bill paid in full?

Yes
No

Did your employer pay charges?

Yes
No

Employed by

Were the items stored in a warehouse?

Yes
No

if 'yes' then where?

Agent Name

Agent City

Agent State/Province

What type of valuation was the shipment moved under?

60 cent/lb. per article (U.S. and Canada)
Declared Value Protection (U.S. Only)
Extra Care Protection/ Customer Transit Protection - no deductible (U.S. and Canada)
Extra Care Protection -$250 deductible (U.S. only)
Extra Care Protection - $500 deductible (U.S. only)

Amount of Coverage

Please enter the information regarding the item you wish to claim. To be processed correctly, the claimed item must include an Inventory Item number OR if your claim resulted from a local or Intra-state move, there may not be any inventory number associated with your claim. NOTE: If the item is repairable but you will accept a nominal cash allowance instead of repairs, enter the amount you are requesting. If repairs are preferred, click the "repair" box. Arrangements may be made to inspect the claimed item. However, please enter a dollar amount claimed and/or click the repair box for every item claimed.

Claim #1

Inventory Item #

Description of Article*

Enter "Missing" or Damage Description*

Weight of Article

Date Purchased

Was the item new or used?

New
Used

Cost When Originally Purchsed

Replacement Cost Today

Amount Claimed

Repair

Claim #2 (If Applicable)

Inventory Item #

Description of Article

Enter "Missing" or Damage Description

Weight of Article

Date Purchased

Was the item new or used?

New
Used

Cost When Originally Purchsed

Replacement Cost Today

Amount Claimed

Repair

Claim #3 (If Applicable)

Inventory Item #

Description of Article

Enter "Missing" or Damage Description

Weight of Article

Date Purchased

Was the item new or used?

New
Used

Cost When Originally Purchsed

Replacement Cost Today

Amount Claimed

Repair

Yes
No

I understand that I cannot repair or dispose of any item prior to carrier authorization and/or inspection. Any item which is repaired or disposed will void damage claim for that item. Also, you may not move an item prior to carrier authorization and or*

Yes
No

Claim Form

Claim form

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