Claim Eligibility Form

Please enter the following information to retrieve and print a claim eligibility form. In order to view or print your CEF form, you will need to use Adobe Acrobat Reader. this free software can be downloaded by clicking here.
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Do not print this screen. A printout of this screen is not considered a valid claims eligibilty form. You must click the PRINT CEF button at the bottom of this form to get your reference number and print a valid CEF to mail.

All questions must be answered fully. Missing or incomplete information will delay the processing of your claim. (* - required)

Claimant information:

First name:
**Last name:
Spouse first name:
Spouse last name:
Other co-owner first name:
Other co-owner last name:
If filing on behalf of a corporation or other entity:
**Name of entity:
Tax ID#:
**Either claimant name or entity name is required.
 
Mailing address:
Street number:
*Street name:
Additional address:
Apt#:
*City:
*State:
*Zip code:
Telephone numbers (format xxx-xxx-xxxx)
Home phone:
Work phone:   ext: 
Spouse's work phone:   ext: 
Email address:
Verify email address:


Property information:

*Date of original PB plumbing or yard service installation:   (format mm/dd/yyyy)

*Date dwelling purchased:   (format mm/dd/yyyy)


*Type of plumbing system (check one or both if applicable):
   PB Plumbing System (inside dwelling)
   PB Yard Service Line
 
Property address:   
Street number:
*Street name:
Additional address:
Apt#:
*City:
*State:
*Zip code:
*Dwelling type:
  If mobile home, list manufacturer and mfg.'s serial number for each section:
    /  


Subdivision, homeowner's association or commerical property information.
Name:
Contact person:
Contact phone:  format xxx-xxx-xxxx)


Do you own this property now? Yes    No
If no, date sold:
If yes, were you the original owner? Yes    No
Has the interior plumbing been replaced? Yes    No
Has the yard service line been replaced? Yes    No


Qualifying leaks claimed:  (help determining leak type)

PB Plumbing System Leaks
(Leaks in the plumbing conducting water to showers, sinks, etc. inside your dwelling)
List in order of leak occurrence. (Leak date format is mm/dd/yyyy)
 
Date of leak Leak location If location is other, describe
1.
2.
3.
4.


If you have additional internal leaks, you can print an additional leak form after submitting this information.

PB Yard Service Leaks
(Leaks in the plumbing conducting water from the water company to your dwelling)
List in order of leak occurrence. (Leak date format is mm/dd/yyyy)
 
Date of leak Leak location If location is other, describe
1.
2.
3.
4.

If you have additional yard service leaks, you can print an additional leak form after submitting this information.

Have you ever been in a lawsuit or received payment from Shell, Celanese, du Pont, your homebuilder, insurance carrier, plumbing contractor or other party relating to damage from or repairs to your PB Plumbing System or PB Yard Service Line with respect to damage of or repair to your plumbing system?
     Yes   No

If yes, explain: 

Are you making a claim for leak expenses or damage to your property not paid by insurance or by other parties?
     Yes   No

How were you referred to our web site?  

Do not print this screen. A printout of this screen is not considered a valid claims eligibilty form. You must click the PRINT CEF button below to get your reference number and print a valid CEF to mail.



Please click the submit button one time. It may take a few seconds to process your information.

(* - required)