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Claim Received – Thank You


[ninja_forms_field id=35],

Thank you for completing the Non-Property Damage Claim Form.  You will receive a confirmation letter in the mail within the next 7-10 business days.  Should you have any questions, please contact us at (877) 412-5277 or

You may retain a copy of your claim submission for your records by clicking the button below:

You may press “Ctrl+P” or “Cmd+P” at any time to print a copy of this claim form submission for your records.

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Question Response
Full name: [ninja_forms_field id=35]
Property address: [ninja_forms_field id=24]
[ninja_forms_field id=29], [ninja_forms_field id=25] [ninja_forms_field id=26]
Current mailing address (if different): [ninja_forms_field id=153]
[ninja_forms_field id=154], [ninja_forms_field id=30] [ninja_forms_field id=32]
Telephone: [ninja_forms_field id=33]
E-mail: [ninja_forms_field id=34]
Customer ID: [ninja_forms_field id=280]
Flushmate System information
Flushmate System serial number: [ninja_forms_field id=131]
Action taken: [ninja_forms_field id=212]
Out of pocket expense: [ninja_forms_field id=146]
Flushmate System serial number (#2): [ninja_forms_field id=132]
Action taken (#2): [ninja_forms_field id=213]
Out of pocket expense (#2): [ninja_forms_field id=147]
Flushmate System serial number (#3): [ninja_forms_field id=133]
Action taken (#3): [ninja_forms_field id=214]
Out of pocket expense (#3): [ninja_forms_field id=148]
Flushmate System serial number (#4): [ninja_forms_field id=134]
Action taken (#4): [ninja_forms_field id=215]
Out of pocket expense (#4): [ninja_forms_field id=149]
File Upload: [ninja_forms_field id=171]
Are you claiming property damage: [ninja_forms_field id=165]
Payment/reimbursement amount: [ninja_forms_field id=58]
Source of payment/reimbursement: [ninja_forms_field id=59]
Signature of claimant: [ninja_forms_field id=61]
Date: [ninja_forms_field id=62]