Claim Form Guide

This section is an agreement between you and the Claims Administrator. It explains how your personal information will be used, shared, and eventually destroyed.

What to do:

• Read the full section carefully before signing
• Print your first and last name
• Sign your name and write today’s date

This part is required for every Claim. It asks for basic information about the Claimant (the person who experienced harm). Take your time — clear and accurate information helps avoid delays. If you’re completing this for someone else, “you” and “your” throughout refer to the Claimant.

① Legal name and Identification

Enter the Claimant’s full legal name exactly as it appears on their government-issued ID.

You must attach a clear copy of the front and the back of the government-issued identification you are providing for the Claimant.

If you don’t have identification, you can reach a Claims Helper by calling the Info Line at 1-888-592-9101 and pressing 2.

② Other names used

Complete this only if the Claimant used a different name in the past. If the Claimant’s name has not changed, or if you do not know of any other names, leave this section blank. If the Claimant’s name did change and you have a document showing the name change, include a copy of that document.

Provide contact details so the Claims Administrator can reach you about your Claim:

• Mailing address
• Email address (if available)
• Phone number(s)