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

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

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

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

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

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



    Click here to add more items

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

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

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

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

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

    INV. #
    ITEM
    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.

    Add Images:


    Electronic Signature:
    Date:


      Reviews from Our Clients

      Review by Kristin Welsh
      Moving Services
      Rating 5 5 Star Moving Rating

      "I had a great experience with Midwest. The movers arrived early, set up my entire home with protective pads and flooring, effectively moved all of my home items, and cleaned up afterward. I have actually used them twice. I had different employees each time, but both crews of men were equally prompt, professional, and efficient. I would highly recommend Midwest."
      Review by Selene
      Moving Services
      Rating 5 5 Star Moving Rating

      "The movers did an incredible job! Our second experience with your company is just as wonderful as our first. Your driver is an incredible leader. The rest of the crew was impressive as well. They all worked tirelessly through out the whole time. This move was stressful with the all the school closings and work changes but they made the whole experience much better."
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      1. In-home Estimate Face-to-face service may be your preference. Schedule an appointment that is convenient for you. We will come out, tour your home in person, and provide a free no-obligation move quote.

      2. Real-Time Video Survey Would you like to have a live video survey done by one of our senior relocation managers? Schedule a phone appointment that is convenient for you. We will connect via an app on your phone and virtually tour your home with you, then provide a free no-obligation move quote.

      3. DIY Video Survey Pressed for time or prefer to do it yourself? Download our virtual move survey app. Follow the process to record the items to be moved, hit send, and get a free move quote shortly after. We will handle everything via phone or email.