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Confirm Class Member Eligibility

Please use this form to confirm your class member eligibility, only if you do not have a Notice ID and PIN. Please enter your name and the mailing addresses exactly as was printed on your postcard notice.

First Name *

First Name *

Last Name *

Last Name *

Address 1

Address 1

Address 2

Address 2

City

City

State

State

Zip Code

Zip Code

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Questions? Contact the Claims Administrator at (833) 360-6875.

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