Damage Claim

Personal Information
First Name*
Last Name*
Email*
Phone*
Date of Move
MM slash DD slash YYYY
Address (Apt #)
City
State
Zip Code
Crew Members
Damaged Item #1
Damaged Item #1
Damage Description Item #1
Make and Model No.
Year Purchased (YYYY)
Estimated Weight
Damaged Item #2
Damaged Item #2
Damage Description Item #2
Make and Model No.
Year Purchased
Estimated Weight
Damaged Item #3
Damaged Item #3
Damage Description Item #3
Make and Model No.
Year Purchased
Estimated Weight
Floor or Wall Damage
Description of any wall or floor damage
Method of Payment you used on moving day
Level of valuation you selected on moving day
"I am the owner of the property described. I did not cause or contribute to the damage set forth herein. All statements made in the Statement of Claim and any attached document (s) are true and correct to the best of my knowledge and believe, and constitute my complete and entire claim. No material or relevant information has been withheld."

Personal Information