Claim Form

Full Name*
Email*
Origin City & State*
Order Number
Street Address
City, State, Zip
Home Phone Number*
Business Phone Number
Delivery Date
Coverage

*Indicate Required Fields

1. Type in full particulars to the best of your ability.

2. Any articles found damaged must be kept available for inspection (including containers).

3. If you already have any estimates for damage claimed, please submit with form.


INV. #
ARTICLE
NATURE OF CLAIM - (Loss, Damage/ Describe)
Est. Weight
Date Acquired
Orig. Cost $
Present Value $
Amount Claimed $

INV. #
ARTICLE
NATURE OF CLAIM - (Loss, Damage/ Describe)
Est. Weight
Date Acquired
Orig. Cost $
Present Value $
Amount Claimed $

INV. #
ARTICLE
NATURE OF CLAIM - (Loss, Damage/ Describe)
Est. Weight
Date Acquired
Orig. Cost $
Present Value $
Amount Claimed $

INV. #
ARTICLE
NATURE OF CLAIM - (Loss, Damage/ Describe)
Est. Weight
Date Acquired
Orig. Cost $
Present Value $
Amount Claimed $

INV. #
ARTICLE
NATURE OF CLAIM - (Loss, Damage/ Describe)
Est. Weight
Date Acquired
Orig. Cost $
Present Value $
Amount Claimed $

INV. #
ARTICLE
NATURE OF CLAIM - (Loss, Damage/ Describe)
Est. Weight
Date Acquired
Orig. Cost $
Present Value $
Amount Claimed $

Total amount claimed (add amounts claimed per item): $

I am the owner of the property described. I did not cause or contribute to the damage set forth herein. All statements made in this statement of claim and any attached documents are true and correct to the best of my knowledge and belief, and constitute my complete and entire claim.

Electronic Signature:
Date: