Damage Claim Form

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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

Damage Description Item #1

Make and Model No.

Year Purchased (YYYY)

Estimated Weight

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."

Personal Information

Address

Damaged Item #1

Damaged Item #2

Floor or Wall Damage

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