Claim Form

Customer Name :

Booking Id :

Phone :

Email :

Street :

Apt :

Invoice # :

City :

State/Province :

Moving to :

Moving from (city, town or prov.) :

Pickup date :

Delivery date :

Additional Comments about your claim :

Item # :


Article


Description of Damage or indicate if lost
Weight


Purchase Date


Purchase Price

Amount Claimed

Serial Code