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CLAIM REGISTRATION Please enter your information
*Indicates Response Required
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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
No
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
*