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2
Name On Contract (Claimant)
*
First
Last
Current Address Of Claimant
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Address Line 1
Address Line 2
City
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Zip Code
Best Contact Number
*
Email
*
Carrier Job Number (Reference #/Job #)
*
Origin State
*
Destination State
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Date Of Pickup
*
Date Of Delivery
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Next
Would You Like To File A Claim Or File A Complaint?
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Claim
Complaint
Claim Category
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Select Claim Reason
Property Damages
Household Goods Damages
Claim Started, Follow Up Request
Were These Items Stored?
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No
Where & How Long?
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Complaint Category
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Select Complaint Reason
Onsite Complaints
Crew Complaints
Revision Complaints
Brief Complaint Description
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