YOU MUST COMPLETE EACH SECTION AND CLICK SUBMIT AT THE END OF THIS ONLINE FORM IN ORDER TO SUBMIT YOUR CLAIM.
Provide your name and contact information below. If your name or contact information changes after you submit this Claim Form, please notify the Claims Administrator of the new information.
There are two possible payment options. Please read the Claim Form Instructions for more information about these options.
(Total amount of documented losses should not exceed the $750 limit per Class Computer claimed)
Please indicate below whether you would like to receive your payment in the form of a check mailed to the address provided in Section A, or if you would like your payment emailed to you to digitally deposit. Please choose only one.*