File a ClaimJanell Darlene2017-01-19T14:00:00-06:00 File a Claim We sincerely regret that your move was not to your complete satisfaction. Your immediate completion of this claim request form will enable us to process your claim. Claims Form Date of Claim* MM slash DD slash YYYY Name of Claimant* First Last Contact InformationCurrent Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Address Moved From* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary Phone*Secondary PhoneEmail* Loss or Damage DiscoveryLoss / Damage Discovered By* Date of Discovery* MM slash DD slash YYYY Moving Date* MM slash DD slash YYYY How Damage OccurredNote If the claim is for breakage to items packed in containers, please provide the following information. Please be advised that we are not responsible for goods that were packed by the shipper and not packed, unpacked, and inspected by our company. Total Value of Goods Shipped on the Bill of Lading ($):NumberFALSE OR FRAUDULENT CLAIMS Any person who knowingly and with intent to defraud any insurance company or person, files a statement of claim what contains any materially false information, or conceals for the purpose of misleading information concerning any factual material is there to committing a fraudulent insurance act, which is a crime. Detailed Statement Showing How Amount Claimed is DeterminedList*List Number, Description of Items, Nature/Extent of Damage or Loss. ETCWeightDate AquiredOriginal CostValue at Time of Loss or DamageAmount Now Claimed Supporting Documents - File Uploads Drop files here or Select files Accepted file types: jpg, gif, png, pdf, doc, xls, Max. file size: 1 MB, Max. files: 5. Images, Documents Supporting Value of Items, Estimates of Damage, ETC.Signature of AgreementThe undersigned, signer of the foregoing statement, hereby makes a solemn oath to the truth of statements contained herein. The undersigned understands that this is to be a complete and accurate listing of damage to be claimed. In no way does this document construe guilt upon the mover or responsibility to reimburse until the proper investigation has been rendered. Name* First Last Date* MM slash DD slash YYYY CAPTCHA Δ
