Claim

Statement Of Claim

Customer Information

4484 Val North Dr. Valdosta, GA 31602

(229) 560-0058

We ask that you complete the form in its entirety. In order for us to process your claim properly, and to avoid delays.

Fill Form Claim

Please fill out this claim form providing as much information as possible about the claim

Check Damage

Upon receipt of your signed and complete claims form, we will take the necessary steps to ensure prompt handling.

Pay Your Claim

Claims for loss or damage must be in writing. If approved, we will process the payment of the claim

Claim Form

First Name

Last Name

Phone Number

Move to

Move From

Date items were loaded up

Date items were delivered

Have transportation charges been paid in full?

Did your employer pay the charges?

Was your shipment stored in our warehouse?

What type of valuation was your shipment moved under?(Insurance)

Date Purchased:

Where Purchased

Phone # of Merchant:

Name of Manufacturer

Manufacturer’s Number

Description of article

Cost when originally purchased: (No estimates accepted)

Replacement Cost Today: (No estimates accepted)

Description of Damage:

Weight of Article:

Amount claimed for “repair”

All questions must be answered in order to proceed with this claim. I understand and agree that all the information provided in this form is true and accurate. I also understand and agree that if any of these spaces are left blank, that this claim will not be processed until the form is completed in its entirety. Note: If there are any more than one damaged item, please make a copy of the: Damaged Items” section of this form and fill out all the information in the same way.

Date