Military Claim Questionnaire Form

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Please provide the following contact information:

Name		Zip/Postal Code
Street Address		Country
Address (cont.)		Home Phone
City		FAX
State/Province		E-mail
GBL Number

1. Were all packable items packed in cartons at origin or residence?

   Yes No
   

2. Were all cartons sealed at origin or residence?

   Yes No
   

3. Were all cartons delivered sealed?

   Yes No
   

4. On crated shipments, were all crates delivered sealed ?

   Yes No
   

5. Was there any carton damage, or did any cartons look like they had been tampered with?

   Yes No
   

6. If answered YES to #6 please explain...

   
   

7. On crated shipments, was there any crate damage or did any crates look like they have been tampered with or dropped?

   Yes No
   

8. Did any of the agents at origin or destination give you any unusual instructions or make unusual comments about your property or the packing of it?

   Yes No
   

9. If answered YES to #9 please explain...

   
   

10. In your opinion what may have caused the damage/loss in your move ?

    
    

11. Is there anything the ORIGIN agent said or did that you witnessed that may have attributed to your loss or damage? If YES please explain.

    
    

12. Is there anything the DESTINATION agent said or did that you witnessed that may have attributed to your loss or damage?

    
    

13. Additional comments: