Contact Us... Online Claims
RESIDENTIAL MOVE CLAIM FORM
YOUR CONTACT INFORMATION
* Indicates required fields.
Your Name*:
Address 1:
Address 2:
City:
State:
ZIP Code:
Home Phone*:
Work Phone:
ext.
Mobile Phone:
E-mail*:
SHIPMENT DETAILS
Shipped From:
Address:
City
ST
ZIP
Shipped To:
Address:
City
ST
ZIP

DETAILS OF DAMAGED ITEMS
Inventory
Number
Item
Name
Weight
of Item
Damage
Desc.
Item
Packed?
Purchase
Date
Purch.
Price
Claim
Amount
1.
Yes
2.
Yes
3.
Yes
4.
Yes
5.
Yes
6.
Yes
7.
Yes
8.
Yes
9.
Yes
10.
Yes
Order/Bill of Lading #:
Pickup Date:
Delivery Date:
Company/Employer : (if applicable)
Who is paying for your move?
Myself My Employer
Yes No Was shipment in a warehouse?
Yes No Are you the owner of the goods in question?
Yes No Do you have certificate of insurance?
Yes No Have all transportation/storage charges been paid?
ADDITIONAL COMMENTS
A hard copy of this Claim form will be sent to you for your signature.
Please promptly return to our Claims department for immediate processing.
Your Signature :
 
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Horizon Moving Systems is an authorized agent for United Van Lines • ICC# MC-67234 • USDOT#077949