Get Consumer Claim Form - Stateagprovigilsettlement.com

Filling out the Consumer Claim Form requires careful attention to detail to ensure your claim is processed correctly. This guide will provide you with a comprehensive step-by-step approach to completing the form online.

Follow the steps to accurately complete the Consumer Claim Form.

1. Press the ‘Get Form’ button to access the form and open it in your preferred online tool.
2. Begin by filling out Section A: Claimant Identification. Enter the name of the individual who paid for ® or its generic version, followed by their street address, city, state, zip code, and daytime telephone number.
3. If the contact person differs from the claimant, complete Section B: Contact Information. Include the contact person's name, their relationship to the claimant, and their contact details.
4. In Section C: Eligibility Questions, answer whether you purchased branded or generic versions of ® between June 24, 2006, and March 31, 2012. You must also indicate if you had prescription benefits that covered any part of your purchase and specify the purchase dates.
5. Proceed to Section D: Purchase Information. State the total amount you paid for ® or its generic versions during the specified period, ensuring you only include amounts not reimbursed by insurance.
6. In Section E: Required Proof of Payment, remember that no documentation is needed right now, but it’s advisable to keep a copy of your receipts, as you may be required to provide proof in the future.
7. Review Section F: The Release, which informs you about the implications of the claim. Be sure you understand this section before you continue.
8. Finally, complete Section G: Sworn Statement Regarding Payments Made. Sign and date the form to confirm that all information provided is accurate, and you are authorized to submit the form on behalf of the claimant if applicable.
9. Save all your changes, and make sure to download or print a copy of the completed form for your records. Submit the form by mailing it to the designated address listed in the instructions, ensuring it is postmarked or received by the deadline.

Complete your Consumer Claim Form online today to ensure your claim is processed in a timely manner.