Progressive Total Loss ClassAction

CLASS MEMBER INFORMATION

Name: *

Street Address 1: *

Street Address 2:

City: *

State: *

Zip Code: *

Email Address:

Contact Phone Number:

CLAIMANT LOSS INFORMATION

Date of Loss *

Mark only those that apply. I was not paid:

Sales Tax

Certificate of Title Fee

Vehicle Registration Transfer Fee

Must Click Add To Submit Your Info.

Date of Loss Checked

Sales Tax Checked

Certificate of Title Fee Checked

Vehicle Registration Transfer Fee Checked

Action

SIGNATURE

AFFIRMATION: BY SIGNING BELOW, I CERTIFY THAT I MADE THE INSURANCE CLAIM(S) IDENTIFIED ABOVE OR I AM THE LEGALLY AUTHORIZED PERSONAL REPRESENTATIVE, GUARDIAN, OR TRUSTEE OF THE PERSON WHO MADE THE CLAIM(S), AND THAT, TO THE BEST OF MY KNOWLEDGE, THE INFORMATION ON THIS CLAIM FORM IS TRUE AND CORRECT. I UNDERSTAND PROGRESSIVE MAY AUDIT MY CLAIM

By typing your name below, you agree that this constitutes your digital signature.

Signature: *

SECURITY CHECK