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

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