Claims Form

STANDARD FORM FOR PRESENTATION OF LOSS AND DAMAGE CLAIM

18 Trescott Street, # 3
Dorchester, MA 02125
Phone: (617) 265-7133
Fax: (617) 822-0593

WeHaul Use Only:

Received:____________

Settled:_____________

RE: Moving Service Invoice: # ______________________________Loss Damage
Name:	E-mail address:
Street :	Phone:
City, State: ZIP Code:	Best Time to Call:

This claim for $_______. ___ is made against your company for Damage/Loss in connection with the following described service:

Detailed statement showing how the amount claimed is determined:
Number and description of articles, nature and extent of loss or damage, invoice price of articles, amount of claim, etc. All Discounts and Allowances must be shown.

The foregoing statement of facts is hereby certified as correct :

Signed: _____________________________________________________ Date: ________________