Property Damage Claim Form

FLUSHMATE CLASS ACTION SETTLEMENT PROPERTY DAMAGE CLAIM FORM

To receive a payment, you must complete this Claim Form and submit it by September 18, 2018. 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:










Current Mailing Address:
(If different from above)










Telephone:









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

B. CLAIM DESCRIPTION











Max file size accepted is 8 mb

C. OTHER PAYMENTS OR REIMBURSEMENTS FOR PROPERTY DAMAGE

Have you or any other owner of the Property ever received any payment or reimbursement from anyone (e.g., Flushmate, insurer, manufacturer, distributor, supplier, contractor or installer) for the cost of repair of the Property Damage caused by a Leak or Burst of the Flushmate System on the Property?




If yes, please indicate:





Please attach copies of documentation showing the amount of the payment(s) and/or reimbursement(s). These payments may be treated as an offset to payments to which you may otherwise be entitled under the terms of the Settlement.





Max file size accepted is 8 mb

D. CERTIFICATION

I/we declare, under penalty of perjury under the laws of the United States of America, that the information set forth 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 concerning this claim, such as contractors, material suppliers, or those who have submitted sworn declarations.

All Claimants indicated on your proof of property ownership should sign.