Please use this document to assist you as you fill out the Claim Eligibility Form.
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I. Claimant Information:  Name(s) of the property owner and the owner's mailing address. There are specific lines for a spouse's name, a co-owner other than a spouse, and a line for another entity such as a commercial property or homeowners association. In the case of a Multi-Unit property, the property owner and/or representative may complete the form. Tenants or renters are not class members; thus the homeowner must be the one to complete the Claim Eligibility Form.

• Last and first name of the homeowner.
• Last and first name of the spouse of the homeowner.
• Last and first name of an owner, other than a spouse.
• Name and Tax ID number of the Corporation or Entity that owns the property that the claim is being filed for. (Commercial property or homeowners associations would use this line.)
• The date the PB system was originally installed in the home. (Date should include the month, day, and year.)
  Documentation of PB install date on Mobile Homes - Acceptable documentation:
  Title, first vehicle registration, or the Settlement statement of the first consumer sale.
  Documentation of PB install date on all dwelling types except Mobile Homes:
  If the PB was installed when the house was built, CPRC needs to verify the date the house was built. Acceptable documentation for the build date would include Certificate of Occupancy, Original warranty deed and/or Settlement Statement (from original purchase), Building or plumbing permits showing date of final inspection.
  If not the original owner, these documents can be obtained at the courthouse in your city or county.
  In the event the original plumbing system has been removed and PB installed in its place, a copy of the replumb receipt and/or replumb permit would document the PB install date.
• The date the dwelling was purchased by the current homeowner. (Date should include the month, day, and year.)
• Mailing Address (Street Address, City, State, Zip Code, and County) where any correspondence should be mailed.
• Home telephone number, work telephone number or other contact number like a cell phone number, spouse's work number or other contact number, and e-mail address.

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II. Property Information:  Information on the type of PB system, property address, dwelling type, and qualifying leaks.

• Specify the PB plumbing system located at the property, which has experienced a leak. One or both (Interior and Yard) may be applicable. PB Yard Service line is the line that runs from the city connection or water source to the first shut off valve of the home.
• Property Address of the property that has incurred a PB leak. (Street Address, City, State, Zip Code and County)
• Dwelling Type of home or building for which this claim is being filed. State whether the property is a mobile home, a single family (site built), a condo unit, town house, an apartment, or a commercial property.
• Mobile homeowners should list the manufacturer and the manufacturer's serial number for each section of the mobile home.
• Subdivision, homeowner's association or commercial property information. This includes the subdivision, homeowner association or commercial property name, the contact person and a telephone number where this contact person can be reached.
• Check "Yes" or "No" to the question: Do you currently own, possess the title or hold the mortgage on the home in which the claim is being filed?
  If not the current owner, list the date it was sold. (Date should include the month, day, and year.)
• Check "Yes" or "No" to the question: Are you the first owner of the home that the claim is being filed for?
• Check "Yes" or "No" to the question: Has the PB Plumbing System inside the home been completely removed or bypassed and replaced with a different material?
• Check "Yes" or "No" to the question: Has the PB Yard Service line been completely removed or bypassed and replaced with a different material?

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III. Qualifying Leaks Claimed.   Attach the following documents for proof of leaks: A copy of repair receipts, photos of repair(s) to the plumbing system, and/or failed parts from the plumbing system.  List the day, month, and year of the leak. If you do not have a dated receipt or other leak date documentation, provide your "best information" as to the month, day and year the leak was discovered. Failure to provide day, month, and year will delay processing.

• PB Plumbing system leaks in the interior of the home.
  Date and location of the leak on the interior PB System. List the month, day and year of each leak. Location could be bathroom, kitchen, laundry room, attic, basement, garage, water heater, or other.
• PB Yard Service leaks. Give the month, day, and year of each leak. List the location of the leak by choosing one of the locations listed. If the leak occurred somewhere in the middle of the line, please list as mid line.
• Check "Yes" or "No" to the question: Have you been in a lawsuit or received payment relating to damage from or repairs to your PB interior plumbing system or PB yard service line? This would include homeowner insurance claims filed for damages resulting from PB leaks. If Yes, please explain on the line provided.
• The Homeowner should sign and date the declaration that the information provided is true to the best of their knowledge. The homeowner agrees to the inspection of the property and examination of records to verify the provided information. A signature is required to begin the claim handling process.
• Check "Yes" or "No" to the question: Are you claiming out of pocket expenses or damages to your property not reimbursed or paid by your insurance carrier or other party? The answer given does not affect the eligibility of a replumb. Leak expense and/or damages may be offered in addition to the PB interior plumbing replacement or the yard line replacement. This could include repayment of insurance deductibles.

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