Full Name

Email

Street Address (where damage occurred)

City

State

Zipcode

Phone Number

Date of service performed

Description of damage

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This claim is a result of (select one)
A household relocationA product delivery/pickupother

"I am the owner of the property described. I did not cause or contribute to the damage set forth herein. All statements made in this statement of claim and any attached documents are true and correct to the best of my knowledge and belief and constitute my complete entire claim. No material information has been withheld. PUCO regulations require that any claim for loss, damage or delay must be submitted in writing by claimant within 60 days from date of delivery."
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