Please make sure you have reviewed our Claim Form Instructions before proceeding. Carrier Order Number*(To file your claim on-line, YOU MUST REFERENCE YOUR CARRIER ORDER NUMBER. It is located in the upper right corner of your Order for Service or Bill of Lading.)Name*Phone*Mobile PhoneEmail* Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Item ClaimInventory Number*(This is found on the Household Goods Descriptive Inventory form)Name/Description of Article*(Appliances, electronic equipment – requires manufacturers’ name, model and serial number. China, Crystal, Statuary – requires manufacturer’s name, number, or other identification. Include colors, full description.)Nature of Claim*(whether damaged or missing, type of damage, etc.)Estimated Weight*When was the item purchased*Purchase Price*Estimated Replacement Cost*Amount Claimed*Was the item packed properly?*Select an answerYesNoWas the carton damaged when you received it?*Select an answerYesNo
