Home ยป Damage Claim Form
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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
Description of any wall or floor damage
Method of Payment you used on moving day
CashCredit CardCheckI don't know
Level of valuation you selected on moving day
BasicPartialFullI don't remember
"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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