ClaimFormNoJONES V. OWNERS INSURANCE COMPANY CLASS ACTION SETTLEMENT CLAIM FORM To receive a settlement payment, you must: complete the information within this online Claim Form (for which you will need the unique Claim Identification Number found on the Claim Form that is attached to your postcard Notice); or fill out and return the Claim Form you received with your postcard Notice, via U.S. Mail, to the address printed on the Claim Form that is attached to your postcard Notice. To submit a claim for settlement payment, you must complete the information below and electronically sign where indicated. Failure to include this information and electronically sign this Claim Form may result in denial of your claim(s). The Claim Form must be submitted no later than February 6, 2024. If submitted by U.S. Mail, the Claim Form must be postmarked by February 6, 2024. If submitted online through the Settlement Website, the Claim Form must be submitted by 11:59 p.m. on February 6, 2024. Your settlement funds will be sent to you by check.Claimant ID(Required) Claim Identification Number(Required) Name(Required) First Last Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email(Required) PhoneThe year, make and model of the vehicle for which I claimed a total loss is:Vehicle Year(Required) Vehicle Make(Required) Model(Required) Acknowledgement(Required) To the best of my knowledge, I am a member of the Settlement Class and the information contained herein is true and correct.
