Interstate Moving Claim Form

Please fill out the form below and a Reebie representative will contact you as soon as possible! To speak to a representative immediately, call 1-800-441-7311 or send an email to Reebie to request information.

Name:
Email address:
Origin Address:
Origin City:
Origin State:	Select State AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
Origin Zip code:
Destination Address:
Destination City:
Destination State:	Select State AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
Destination Zip code:
Telephone number:

Registration number:
Load Date:
Storage Agent:
Declared value:
If employer pay for move, indicate employers name:
Total amount claimed:

Inventory item number:
Description of article:
Description of damage:
Weight of article:
Date of purchase:
Purchased From:
Original purchase price:
Replacement Cost:
Amount claimed: