CLAIM REGISTRATION Please enter your information
*Indicates Response Required
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Your Current Address
Alt. Phone Number
Is it allright to communicate with you via email?
Name Of Moving Company
Pick Up Date
Were Your Items Stored?
If YES... How Long & Where?
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?
Did You Purchase Additional Insurance?
Name of Insurance Company
LIST OF DAMAGED ITEMS Enter the Lost or Damaged Items Below
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