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Consumer Claim Form
Please fill in all of the
Required Fields
below. When completed turn off your web browser's Pop-Up Blocker and click
"Create Printable Claim Form".
Once you click "Create Printable Claim Form", you can either:
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Print the Claim Form, fill out remaining information, and submit to the Claims
Administrator with any relevant supporting documentation, or
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Save the Claim Form as a .PDF file on your computer for completion at a later
time
If you require assistance with this process, please
call 1-800-572-0455.
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