File a Claim

Customer Information

Name on Bill of Lading/Contract*

Phone Number*

Alternate Phone Number

Email*

Current Address*

City*

State*

ZIP Code*

Information About Your Move

Order Number*

Type of Move*

Origin Address*

Pickup Date*

Destination Address*

Delivery Date*

Were you household goods placed in storage?*

Yes

If so, where and now long?*

Valuation Coverage

1. Was the shipment released at carrier's basic valuation at $0.60 per pound per article?*

Yes

No, I used 3rd party insurance

1 a. Please state the 3rd party insurance provider*

Items Damaged or Lost

Item

Inventory #

Description of Damage

Lost or Damaged?

Who packed this item?

Purchase Date

Add item by clicking the + button below

Upload Photos of Damaged Items

Drop files here or

Accepted file types: jpg, jpeg, gif, png, webp, Max. file size: 4 MB, Max. files: 20.

Additional Information/Description Regarding Claim

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 documents are true and correct to the best of my knowledge and belief, and constitute my complete and entire claim. No material information has been withheld. Element Moving reserves the right to require notarized statement or affidavit:

Signature of Claimant*

Printed Name*

Date*