Your Claim Form has been submitted successfully.
Please print this page for your records.
Your Claim Details
| Submitted Claim ID: | |
| Confirmation Code: | |
| You will need the above Submitted Claim ID and Confirmation Code if you would like to edit your Claim at a later time, so please print this page for your records. | |
| CLAIM INFORMATION | |
| First Name | |
| Last Name | |
| Street Address | |
| City | |
| State | |
| Zip Code | |
| Email Address | |
| Signature | |
| Date |
If you have any questions regarding your Claim, please provide the Submitted Claim ID listed above and email us at Questions@PlaidSettlement.com.
Click here to edit your Claim.