Second Claim Form Page

[gravityform id=”2″ title=”false” description=”false” field_values=”first_name={Name (First):1.3}&last_name={Name (Last):1.6}&email={Email:2}&street_address={Origin Address (Street Address):5.1}&city={Origin Address (City):5.3}&state={Origin Address (State / Province):5.4}&zip_code={Origin Address (ZIP / Postal Code):5.5}&dstreet_address={Delivery Address (Street Address):6.1}&dcity={Delivery Address (City):6.3}&dstate={Delivery Address (State / Province):6.4}&dzip_code={Delivery Address (ZIP / Postal Code):6.5}&dphone={Phone Number w/ Area code::7}&mdate={Move Date/Load Date::10}&dregistration={Registration Number or Bill of Lading Number::9}&storageagent={Storage Agent::11}&employer={Employer (if employer paid for move)::12}”]
Reebie Chicago Movers
Allied Agent