Damage Claim Form

    Personal Information
    First Name* :
    Email* :
    Last Name :
    Phone* :
    Address
    Street Address :
    City :
    Postal / Zip Code :
    Address Line 2 :
    State / Province / Region :
    Country / Region

    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 (YYYY)

    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."

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