Claim Form - Jul '21

Rev. Jul '21 Email: [email protected] // Fax: 800-977-5591 // Mail to: Claims Dept., PO Box 1073, Point Pleasant Beach, NJ 08742

Be sure to fill out ALL fields for EVERY Manufacturer you claim. Failure to do so may result in a Manufacturer Denial

Rev. Jul '21 Email: [email protected] // Fax: 800-977-5591 // Mail to: Claims Dept., PO Box 1073, Point Pleasant Beach, NJ 08742

Be sure to fill out ALL fields for EVERY Manufacturer you claim. Failure to do so may result in a Manufacturer Denial

Rev. Jul '21 Email: [email protected] // Fax: 800-977-5591 // Mail to: Claims Dept., PO Box 1073, Point Pleasant Beach, NJ 08742

Be sure to fill out ALL fields for EVERY Manufacturer you claim. Failure to do so may result in a Manufacturer Denial

Rev. Jul '21 Email: [email protected] // Fax: 800-977-5591 // Mail to: Claims Dept., PO Box 1073, Point Pleasant Beach, NJ 08742

Be sure to fill out ALL fields for EVERY Manufacturer you claim. Failure to do so may result in a Manufacturer Denial

(If you combined the information on the previous page(s), pleaseidentify which Manufacturers apply to which addresses below:)

View and Learn More Here: HBArebates.com/AP

Rev. Jul '21 Email: [email protected] // Fax: 800-977-5591 // Mail to: Claims Dept., PO Box 1073, Point Pleasant Beach, NJ 08742

Address or Lot/Block City & State Completed Date