Moving Customer - Report of Loss
Today's Date
*
-
Month
-
Day
Year
Date Picker Icon
CUSTOMER INFORMATION
CUSTOMER FULL NAME
*
DAYTIME PHONE #
*
CUSTOMER ADDRESS
CUSTOMER EMAIL
*
if none, enter store email
MOVER INFORMATION
MOVER COMPANY NAME
*
MOVER COMPANY'S ADDRESS
MOVER'S PHONE #
1. Cause of Loss. Was your property damaged by one or more of the following? (check all that apply)
*
Mover's negligence
Damage during the act of loading or unloading by mover
Damage during transport resulting from improper packing or loading by mover
Other
2. Please explain what you believe happened to your property:
*
3. When do you think the damage happened? (Please be specific)
*
3A. When did your move take place?
*
3B. When did you discover your loss?
*
4. Did you notify the mover of the loss? If so, when?
*
4A. What was the mover's response?
*
4B. Has the mover already paid a portion of the damage? If so, how much?
*
THIS SECTION TO BE COMPLETED BY CUSTOMER IMMEDIATELY FOLLOWING THE LOSS.
Items must also be listed on Mover's Inventory Sheet
List of Damaged or MIssing Property
*
Rows
Item
Damage Amount
Repair Amount
Replace Amount
Receipt (yes or no)
1.
2.
3.
4.
5.
6.
7.
8.
9.
Totals-
Photos
Upload a File
please attach any photos of the damage
Cancel
of
Signature
*
_________________________________________________________________________
Submit
Should be Empty: