Claim Form

CLAIM FORM

Thank you for allowing Dircks Moving Services to service your recent relocation.

For your convenience, we have provided an on-line Claim Form to expedite the claim process. Please complete the claim form that follows and transmit it to us.

Receipt of your claim will be acknowledged and a Claims Adjustor will be assigned. Your Claim Adjuster will review the claim and contact you, if necessary, with any further instructions.

Since all damaged items are subject to inspection, please do not proceed with any repairs, and do not dispose of any damaged items or boxes. A "comments" section has been provided at the end of the claim form should you need to provide further explanation for any items or issues referenced in your claim.

If we can be of any further assistance, please contact us at one of our toll free numbers :

Your name (and the name of the Mayflower customer, if different)*
Your shipment's 5-digit (Canada) or 6-digit (U.S.) registration number*
Home Phone* Business Phone* Extension



Your Fax Number Your Email Address*


Moved To: (Destination Address)*
Address
City
State/Province Zip/Postal Code
Moved From (Origin Address)*
Address
City
State/Province Zip/Postal Code
Present Address*
Click if same as "Moved To:" address above.
Address
City
State/Province Zip/Postal Code
The date your items were loaded onto the truck*
The date your items were delivered*
Have transportation charges been paid in full?*

Did your employer pay the charges?*

Employed by
Was your shipment stored in a warehouse?

If 'YES', where?
Agent Name
City
State/Province
Under what type of valuation was your shipment moved?*
Select One:




$ amount

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