File A Claimmalik2022-08-16T22:55:56+00:00 File A Claim We sincerely regret that your move was not to your complete satisfaction. Your immediate completion of this claim request form will enable us to process your claim. The following claim form must be fully completed. Submitting an incomplete claim form will result in delays in claim processing and/or claim denials. Please be as thorough as possible and list any damaged items separately where requested below. Date of Claim* MM slash DD slash YYYY Name of Claimant* First Last Contact InformationCURRENT ADDRESS* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code ADDRESS MOVED FROM* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary Phone Number*Secondary Phone NumberEmail* Loss or Damage DiscoveryLoss / Damage Discovered By* Date of Discovery* MM slash DD slash YYYY Moving Date* MM slash DD slash YYYY How Damage Occurred*Note Please be advised that we are not responsible for goods that were packed by the shipper and not packed, unpacked, and inspected by our company. Total Paid to Fox Moving For Services: ($) *Detailed Statement Showing How Amount Claimed is DeterminedBelow, you must list each item claimed for damages - one item per line. Use the + to add an additional line and complete each field as requested. One item per line and ALL information must be provided including a weight of item claimed and current value. If the damage is to property with no weight to be assessed (i.e. floors or walls), please type "NA" into the weight field. Any fields with any inappropriate or missing information may lead to a need to resubmit your claim and will delay the settlement process.*List Number, Description of Items, Nature/Extent of Damage or Loss. ETCWeightDate AquiredOriginal CostValue at Time of Loss or DamageAmount Now Claimed Supporting Documents - File Uploads Drop files here or Select files Accepted file types: jpg, gif, png, pdf, doc, xls, Max. file size: 1 MB, Max. files: 5. Images, Documents Supporting Value of Items, Estimates of Damage, ETC.FALSE OR FRAUDULENT CLAIMS Any person who knowingly and with intent to defraud any insurance company or person, files a statement of claim what contains any materially false information, or conceals for the purpose of misleading information concerning any factual material is there to committing a fraudulent insurance act, which is a crime. Signature of AgreementThe undersigned, signer of the foregoing statement, hereby makes a solemn oath to the truth of statements contained herein. The undersigned understands that this is to be a complete and accurate listing of damage to be claimed. In no way does this document construe guilt upon the mover or responsibility to reimburse until the proper investigation has been rendered. Name* First Last Date* MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged.
