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
Moved From Address
Moved To Address  
TRANSACTION INFORMATION
Load Date (mm/dd/yyyy):   

Delivered Date (mm/dd/yyyy):      

Was the Shipment stored in a warehouse?               
If the shipment was stored in a warehouse, then where?   
Have Transportation Charges been paid in full?

Did Claimant's employer pay the charges?
If employer paid for move then...Employed By:
COMMENTS







ITEM INFORMATION
        
 Item #Item DetailDamage DescriptionDate PurchasedGiftOriginal CostReplacement CostAmount ClaimedRepair YES/NO
Remove         
Item#:
Item Detail:
Damage Description:
Date Purchased:
Gift?:
Original Cost:
Replacement Cost:
Amount Claimed:
Repair?:



Have questions?...Please call Tonya at (800) 747-4100 ext 2205 (Monday thru Friday 8am to 5pm (CST))