CLAIM FORM

"Please fill out this form carefully providing as much information as you can, the more information you provide, the easier it will be to process your claim and you can expect faster response time from the moving company you used."

Company Name

US DOT

Company Email

Company Phone Number

Website

Reason for Claim

Customer Name

Job No.

Phone

Email

Pickup Address

Destination Address

It can be Moving Into a Home or Apartment?

Describe Damage/Loss Below Clearly

* What was the coverage selected for your move?

$0.60 Per Lb. Per Article
Full Value Protection

If FVP, what was the Declared Value and Deductible?

Ded.

Inventory No
Item Weight
Item Description
Lost
Description of damage
Claimed amount
More+

Overcharge (Please Explain)


Fill in Dates of Service

Pickup date
Delivery date
Delivery Date Window
Actual date s
Late Days Claimed
$ Claimed Amount *
*By signing below, I acknowledge and agree that the items or servicesd hereon constitute my complete and entire claim. I understand that by filing this claim, I waive my right to file any other claims pertaining to this move under the job number noted above. I agree that I will provide pictures supporting the damages claimed and pictures to show the entire item if applicable and copies of any documents supporting any other type of claim I am filing for.

Customer Signature

Date

FOR OFFICE
USE ONLY
Claim #
Received Date
Date Settled
Settled By
Date Paid
Check #

We are not a claim company, we provide you the proper tools to file a claim, said filling of a claim remains in your hands after you are given all the proper tools which we provide with all rights reserved. I hereby understand this and waive any legal action against blogpartnerka.ru Enterprise Corp for my future use of said tools

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