CLAIM REGISTRATION Please enter your information

*Indicates Response Required ? Click on for Help with the field

Your Name

First Name

Last Name *

Your Current Address

Street Address

STATE

City

Zip

Phone Number

Alt. Phone Number

Email Address *

Confirm Email *

Is it allright to communicate with you via email? *

Yes

Move Information

Name Of Moving Company * 🛈

JOB # 🛈

Pick Up Date 🛈 +

Delivery Date 🛈 +

From State 🛈

To State 🛈

Were Your Items Stored?

YES

N O

If YES... How Long & Where?

0/100 characters

What Valuation did you select? 🛈

Valuation A- $.60/lb/item Limited Liability

Valuation B- Full Value Protection (FVP)

If you chose Option B (FVP) what is your Deductible?

$0 Deductible

$250 Deuctible

$500 Deductible

Did You Purchase Additional Insurance?

YES

N O

Name of Insurance Company

LIST OF DAMAGED ITEMS Enter the Lost or Damaged Items Below

Inv # 🛈

Item Description

Damage Description or "MISSING"

UPLOAD PICTURES OF DAMAGED ITEMS

You may upload pictures of the damaged items here. Please ZIP your pictures and enter that file name here.

Maximium size of the file is 20 Megabytes

ZIPed file Name

To print a copy: make sure you have selected Landscape in File/Page Setup > then select File/Print

Enter the word in the image *
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