Claims Information Form

Which Office Moved You:
Customer Name: *
Address: *
City: *
State: *
Zip: *
Phone Number: *
Moved From: *
Pick Up Date: *
Delivery Date: *
   
Item #1  
Inventory # *
Article Name: *
Description of Damage: *
Purchase Date: *(MM/DD/YY)
Purchase Price: *
Claim Amount:
   
Item #2  
Inventory # *
Article Name: *
Description of Damage: *
Purchase Date: * (MM/DD/YY)
Purchase Price: *
Claim Amount:
   
Item #3  
Inventory # *
Article Name: *
Description of Damage: *
Purchase Date: *(MM/DD/YY)
Purchase Price: *
Claim Amount:
   
Item #4  
Inventory # *
Article Name: *
Description of Damage: *
Purchase Date: * (MM/DD/YY)
Purchase Price: *
Claim Amount:
   
Item #5  
Inventory # *
Article Name: *
Description of Damage: *
Purchase Date: * (MM/DD/YY)
Purchase Price: *
Claim Amount: *
 

*Denotes required fields.

If you have more than five items, please call
Appleton, WI at (800) 242-3577 or Milwaukee, WI at (800) 950-1717.


If you have less than five items, please enter N/A in all other fields.

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©1998 Schroeder Moving Systems, Inc.
Schroeder is an authorized agent for United Van Lines

I.C.C. No. MC-67234 US DOT #077949







Appleton, WI
2720 East Winslow Ave.
(920) 739-5533
(800) 242-3577


Milwaukee, WI
15700 West Lincoln Ave.
(262) 784-1717
(800) 950-1717