Claim Form - Jul '21
Transcript of Claim Form - Jul '21
![Page 1: Claim Form - Jul '21](https://reader033.fdocuments.in/reader033/viewer/2022050419/6270fe17130eea4d4e63e114/html5/thumbnails/1.jpg)
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
![Page 2: Claim Form - Jul '21](https://reader033.fdocuments.in/reader033/viewer/2022050419/6270fe17130eea4d4e63e114/html5/thumbnails/2.jpg)
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
![Page 3: Claim Form - Jul '21](https://reader033.fdocuments.in/reader033/viewer/2022050419/6270fe17130eea4d4e63e114/html5/thumbnails/3.jpg)
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
![Page 4: Claim Form - Jul '21](https://reader033.fdocuments.in/reader033/viewer/2022050419/6270fe17130eea4d4e63e114/html5/thumbnails/4.jpg)
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
![Page 5: Claim Form - Jul '21](https://reader033.fdocuments.in/reader033/viewer/2022050419/6270fe17130eea4d4e63e114/html5/thumbnails/5.jpg)
(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