Non-Property Damage Claim Form

FLUSHMATE CLASS ACTION SETTLEMENT NON-PROPERTY DAMAGE CLAIM FORM

To receive a payment, you must complete this Claim Form and submit it by September 18, 2018. If you have sustained Property Damage, you need to complete a separate Property Damage Claim Form. Both forms may be submitted online, or by e-mail, U.S. Mail or facsimile at the addresses listed at the bottom of this page.


A. CLAIMANT AND PROPERTY INFORMATION


Property Address:

(Claimant information should match ownership of property)












Current Mailing Address:
(If different from above.)
















Your Customer ID Number is listed above your address on the postcard notice that you may have received regarding this class action settlement.
 

B. FLUSHMATE TOILET AND FLUSHMATE SYSTEM INFORMATION

For each Flushmate Toilet(s) you own or have owned, did you have a Repair Kit, replacement pressure vessel, or replacement toilet installed?

If yes, please list the serial number for each "Flushmate System" for which you are seeking payment, indicate the action taken, and state the amount of out-of-pocket expenses, if any, associated with the installation.
































If you incurred unreimbursed out-of-pocket installation expenses, please upload copies of your invoices or receipts with this Claim. If you do not have invoices or receipts, you can still submit your Claim listing the serial number or providing other proof of ownership of the Flushmate System(s) for which you are seeking reimbursement in the fields above.





Max file size accepted is 8 mb

C. PROPERTY DAMAGE

Are you claiming direct Property Damage caused by a Flushmate System that has Leaked or Burst?




If yes, please click here to complete the Property Damage Claim Form or call the Claims Administrator at (877) 412-5277.

D. OTHER PAYMENTS OR REIMBURSEMENTS FOR OUT-OF-
POCKET INSTALLATION EXPENSES

Have you, at Flushmate's expense, had a Repair Kit installed on your Flushmate Toilet, a replacement vessel installed in your Flushmate Toilet, or a Flushmate Toilet replaced because of a Leak or Burst?




Have you ever received any payment or reimbursement from anyone (e.g., insurer, manufacturer, distributor, supplier, contractor or installer) for having installed a Repair Kit, a replacement pressure vessel, or a replacement toilet in place of your Flushmate Toilet?




If yes, please provide:





E. CERTIFICATION

I/we declare, under penalty of perjury under the laws of the United States of America, that the information in, and submitted with, this Claim Form is true and correct to the best of my/our knowledge and belief. I/we authorize the Claims Administrator to contact anyone else who may have supplied information or documentation about this claim, such as contractors, material suppliers, or declarants.