A. van Leeuwenhoeksweg 50, 2408 AN Alphen aan den Rijn
+31 (0)172-449977
A. van Leeuwenhoeksweg 50, 2408 AN Alphen aan den Rijn   

We regret that damages have occurred during the move of your household goods. We do however take full responsibility!

Please read this instruction carefully before completing this form. Please fill out this form completely. We will acknowledge receipt of your claim within 48 hours.

If possible/applicable please upload a copy of the purchase receipt or a quotation of repair and (digital) pictures of the damaged items.

Please enter below your e-mail address in order to receive a copy of the data submitted by you.

    Your personal information

    Last name

    E-mail address

    Please provide your daytime phone number*

    Order number*


    When did you find out about the damages.

    Did you report the damages to us earlier.

    If yes, whom

    Banking Details

    IBAN number

    For international transfers please also include following details.

    Your full address


    Name of your bank

    Full address of your bank

    Overview of Damages

    Description in damage
    Purchase date
    Purchase amount in €
    Claim amount in €

    * Inventory item: please indicate the corresponding number on the descriptive inventory.

    If above not enough space please use this document or attach your own list. We kindly request you NOT to dispose of any damaged items. After receipt of the completed form we will check whether the form has been completed correctly and is provided with enclosures. When complete we will send the damage claim to our insurer. The insurer will the decide if a reimbursement will be made based on these documents or that an assessment by an expert will be necessary. For further details we refer to our General Conditions.

    File with list of goods


    I hereby declare to have completed this form to the best of my knowledge. A false or incorrect claim can lead to rejection or a delay in settling the claim.

    When you use this form, you agree to the storage and processing of your data through this website.