Initial Damage & Loss Form

Initial Damage & Loss Form
IMPORTANT INFORMATION: This is not a claim form. This form is used to submit a request to file a claim with Wirks Moving & Storage. Completing this form does not constitute a properly presented claim under Uniform Bill of Lading Section (2B). A properly presented claim will require you to provide an estimated replacement value and description of damage or loss.

Wirks Moving & Storage will issue a claim number and send a claim form via email to the email address on file upon receipt of this document.

PLEASE COMPLETE THE FOLLOWING INFORMATION:
Date Of Move

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Shipper's Name
Shipper's Phone
Shipper's Email
Damage To (Check all that apply)
Detailed Statement Of Reported Damages
Household Goods Reported Missing From Shipment
Shipper's Comments
Upload Supporting Documents

Cancelof
Signature Of Shipper
Should be Empty: