CLAIM FORM
CUSTOMER INFORMATION
Registration Number:
First Name:
Last Name:
Email Address:
Contact Numbers:
Home / Mobile Phone
Work / Business Phone
Fax
Street
City
State
Zip Code
Country
Current Address
NONE
AB
AK
AL
AR
AZ
BC
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
LB
MA
MB
MD
ME
MI
MN
MO
MS
MT
NB
NC
ND
NE
NF
NH
NJ
NM
NS
NT
NV
NY
OH
OK
ON
OR
PA
PE
PQ
RI
SC
SD
SK
TN
TX
UT
VA
VT
WA
WI
WV
WY
YT
Moved From Address
NONE
AB
AK
AL
AR
AZ
BC
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
LB
MA
MB
MD
ME
MI
MN
MO
MS
MT
NB
NC
ND
NE
NF
NH
NJ
NM
NS
NT
NV
NY
OH
OK
ON
OR
PA
PE
PQ
RI
SC
SD
SK
TN
TX
UT
VA
VT
WA
WI
WV
WY
YT
Moved To Address
NONE
AB
AK
AL
AR
AZ
BC
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
LB
MA
MB
MD
ME
MI
MN
MO
MS
MT
NB
NC
ND
NE
NF
NH
NJ
NM
NS
NT
NV
NY
OH
OK
ON
OR
PA
PE
PQ
RI
SC
SD
SK
TN
TX
UT
VA
VT
WA
WI
WV
WY
YT
TRANSACTION INFORMATION
Load Date (mm/dd/yyyy):
Delivered Date (mm/dd/yyyy):
Was the Shipment stored in a warehouse?
Yes
If the shipment was stored in a warehouse, then where?
Origin
Destination
Have Transportation Charges been paid in full?
Yes
Did Claimant's employer pay the charges?
Yes
If employer paid for move then...Employed By:
COMMENTS
ITEM INFORMATION
Item #
Item Detail
Damage Description
Date Purchased
Gift
Original Cost
Replacement Cost
Amount Claimed
Repair YES/NO
Remove
Item#:
Item Detail:
Damage Description:
Date Purchased:
Gift?:
Yes
Original Cost:
Replacement Cost:
Amount Claimed:
Repair?:
Yes
Have questions?...Please call us at (800) 747-4100 ext 2205 (Monday thru Friday 8am to 5pm (CST))