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Claim Form

This website allows Class Members to view and print a customized Claim Form in PDF format. Please enter the information requested below and it will be printed on your Claim Form. When you have completed the form below, please review, download and print your claim form and submit it to the Claims Administrator via one of the three filing methods described on this website.

(* indicates a required field)

Do not use this Claim Form to request a bumper for your iPhone 4. Go to for instructions on how to request a bumper.

Please enter the Class Member’s name and address:

*First name:
*Last name:
C/o or Attn:

Please enter your mailing address:


Please enter additional contact information (optional):

Daytime Telephone Number:-- 
Evening Telephone Number:-- 
Email Address:
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