Claims Online

To file your claim, please complete all of the appropriate fields below. Please make sure that you have completely unpacked and found all items that you may wish to claim to ensure that your account is handled in the fastest and most efficient manner possible. We appreciate your business and sincerely hope to make the filing and settling of your claim as simple as possible. After receipt of your form, a claims adjuster will contact you as soon as possible.

First Name:*
Last Name:*
Primary Phone:*	ext.
Secondary Phone:	ext.
Email:*
Best time to contact you:	A.M. P.M. Any Time
Delivery Address Information:
Address Line 1:*
Address Line 2:
City:*
State:*
Zip Code:*
Pick Up Address Information:
Address Line 1:
Address Line 2:
City:
State:
Zip Code:
Order/Registration Number:*
Load Date:	January February March April May June July   1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24   2007 2008
Delivery Date:	January February March April May June July   1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24   2007 2008
Did employer pay for move?	Yes No
Employer:
National Account Number:
What was declared value protection?	$0.60/lb $1.25/lb $5.00/lb Lump Sum $   Full Value Don't Know
1   2 3   4 5 6 Inventory number Article weight Article desc Desc of loss/damage Date of purchase/ Age of item Cost to replace Amount claimed Carton damaged? Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No
Remarks: