CHICAGO MOVING | CHICAGO MOVER | ILLINOIS MOVERS | MOVING COMPANY CHICAGO | Bernard Movers

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Claims

INV. #	ARTICLE	NATURE OF CLAIM - (Loss, Damage/ Describe).
Est. Weight lbs	Date Acquired	Orig. cost $	Present Value $	Amount Claimed $

INV. #	ARTICLE	NATURE OF CLAIM - (Loss, Damage/ Describe).
Est. Weight lbs	Date Acquired	Orig. cost $	Present Value $	Amount Claimed $

INV. #	ARTICLE	NATURE OF CLAIM - (Loss, Damage/ Describe).
Est. Weight lbs	Date Acquired	Orig. cost $	Present Value $	Amount Claimed $

INV. #	ARTICLE	NATURE OF CLAIM - (Loss, Damage/ Describe).
Est. Weight lbs	Date Acquired	Orig. cost $	Present Value $	Amount Claimed $

INV. #	ARTICLE	NATURE OF CLAIM - (Loss, Damage/ Describe).
Est. Weight lbs	Date Acquired	Orig. cost $	Present Value $	Amount Claimed $

Total amount claimed (add amounts claimed per item): $

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 and entire claim.

Electronic Signature: Date: 03/12/2010

humanresources@bernardmovers.com | Phone: 1-773-883-0780 | Toll Free: 1-800-661-3902 | ILCC 137377