Submit Claim

YOU MUST COMPLETE EACH SECTION AND CLICK SUBMIT AT THE END OF THIS ONLINE FORM IN ORDER TO SUBMIT YOUR CLAIM.

I. Provide Your Contact Information:

Provide your name and contact information below. It is your responsibility to notify the Settlement Administrator of any changes to your contact information after the submission of your Claim Form.

First Name*

Please enter a valid first name (min 2 characters)

Last Name*

Please enter a valid last name (min 2 characters)

Street Address 1*

Please enter a valid street (min 2 characters)

Street Address 2

Please enter a valid street (min 2 characters)

City*

Please enter a valid city (min 2 characters)

State*

Zip Code*

Invalid ZIP code. Format: 12345

Home Phone*

Invalid phone number. Format: 1234567890

Cell Phone

Invalid phone number. Format: 1234567890

Work Phone

Invalid phone number. Format: 1234567890

Email Address*

Emails do not match.

Confirm Email Address*

Emails do not match.

Notice ID Number (Optional) (Please enter your Notice ID Number, if you received a Notice by mail or email)

1. Please select applicable. Are you a: *

Plumber

Tenant

Builder

Home Owner

Insurer

Owner of Commercial or Rental Property

Other

2. Are you making a Claim for a Business or Entity? *

Yes

II a. DESCRIPTION OF PROPERTY WHERE THE QUALIFYING LEAK(S) OCCURRED

A. Property address

Property Street Address 1*

Please enter a valid street (min 2 characters)

Property Street Address 2

Please enter a valid street (min 2 characters)

Property City*

Please enter a valid city (min 2 characters)

Property State*

Property Zip Code*

Invalid ZIP code. Format: 12345

B. Property ownership

Name of Property Owner (List the full name of all Property Owners) *

Please enter a valid name (min 2 characters)

+ Add Additional Property Owner Name

1. Are you the current owner of the property? *

Yes

2. Was an insurance claim made concerning Qualifying Leak(s)? *

Yes

3. Are you a builder, contractor, distributor, seller, subrogated insurance carrier, or other Person who has claims for contribution, indemnity or otherwise for amounts you paid due to leaks at the properties of others?* (You must provide documentation and evidence of payments in order for your claim to be complete).

Yes

Full Name *

Please enter a valid name (min 2 characters)

Mailing Address 1 *

Please enter a valid street (min 2 characters)

Mailing Address 2

Please enter a valid street (min 2 characters)

City *

Please enter a valid city (min 2 characters)

State *

Zip Code *

Invalid ZIP code. Format: 12345

Phone Number *

Invalid phone number. Format: 1234567890

Alternate Phone Number

Invalid phone number. Format: 1234567890

Email Address *

Invalid phone number. Format: 1234567890

Supporting Documents

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C. Property type

Property Type *

II b. DESCRIPTION OF PROPERTY WHERE THE QUALIFYING LEAK(S) OCCURRED

D. Installation information

1. Do you know the builder of your structure with Tubing, Fittings, and/or Clamps? *

Yes

Company Name *

Please enter a valid name (min 2 characters)

First Name *

Please enter a valid first name (min 2 characters)

Last Name *

Please enter a valid last name (min 2 characters)

Street Address 1 *

Please enter a valid street (min 2 characters)

Street Address 2

Please enter a valid street (min 2 characters)

City *

Please enter a valid city (min 2 characters)

State *

Zip Code *

Invalid ZIP code. Format: 12345

Phone Number *

Invalid phone number. Format: 1234567890

2. Do you know who installed the Tubing, Fittings, and/or Clamps? *

Yes

Company Name *

Please enter a valid name (min 2 characters)

First Name *

Please enter a valid first name (min 2 characters)

Last Name *

Please enter a valid last name (min 2 characters)

Street Address 1 *

Invalid characters found

Street Address 2

Please enter a valid street (min 2 characters)

City *

Please enter a valid street (min 2 characters)

State *

Zip Code *

Invalid ZIP code. Format: 12345

Phone Number *

Invalid phone number. Format: 1234567890

3. Estimated Installation Date *

Installed when structure was originally built.

Installed after original construction of the structure.

Do not know.

E. Homeowner insurance

If you are claiming as a homeowner, identify the name and policy number of your homeowners insurance in effect at the time of your Qualifying Leak:

1. Are you claiming as a homeowner? *

Yes

VI. SETTLEMENTS

Have you entered into any oral or written settlement of the claims identified above, or received the benefit of any payments to you or on your behalf as a result of those claims? * (If Yes, please attach a copy of the Release or Settlement Agreement, if any.)

Yes

Party to the Settlement *

Date of the Settlement *

Amount of the Settlement ($) *

+ Add additional row

Supporting document

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Click ADD after you have entered the Settlement information above.

VII. ADDITIONAL INFORMATION

Have you previously contacted NIBCO about one or more of the leaks identified in this claim form? *

Yes

If you have any additional information which you would like us to consider in evaluating your claim, please attach that information as a separate document.

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VIII. WORK AUTHORIZATION

By signing and returning this Claim Form, I accept the terms of the Settlement and authorize the Claims Administrator to schedule inspection, repairs, and/or a re-plumb of the property, as applicable.

IX. RELEASE, CERTIFICATION, AND AGREEMENT TO BE BOUND

I/we declare that the information that I/we have supplied in this Claim Form is true and correct to the best of my/our knowledge and belief and that this document is signed pursuant to 28 U.S.C. § 1746 under penalty of perjury. By signing below, I/we hereby certify that I/we have read the Release in Paragraph 34 of the Settlement Agreement and agree to be bound by the Release and the Settlement Agreement.

Signature of Claimant * (Type your name here to electronically sign your Claim Form)

Date *

Signature of Claimant (Optional) (Type your name here to electronically sign your Claim Form)

Date (Optional)

* Required Fields

KIMBERLY COLE, et al, on behalf of themselves
and all others similarly situated, Plaintiffs, vs.
NIBCO, Inc., Defendant

UNITED STATES DISTRICT COURT FOR THE
DISTRICT OF NEW JERSEY

Civil Action No. 13-cv-7871 (FLW)(TJB)

THANK YOU FOR SUBMITTING YOUR CLAIM.

I. Provide Your Contact Information:

II a. DESCRIPTION OF PROPERTY WHERE THE QUALIFYING LEAK(S) OCCURRED

II b. DESCRIPTION OF PROPERTY WHERE THE QUALIFYING LEAK(S) OCCURRED

III. IDENTIFICATION AND INSTALLATION OF TUBING, FITTINGS, and CLAMPS

IV. DESCRIPTION OF LOSS

V. RE-PLUMB CLAIMS

VI. SETTLEMENTS

VII. ADDITIONAL INFORMATION

VIII. WORK AUTHORIZATION

IX. RELEASE, CERTIFICATION, AND AGREEMENT TO BE BOUND

Submitted Claim ID:
Confirmation Code:
You will need the above Submitted Claim ID and Confirmation Code if you would like to edit your Claim at a later time, so please print this page for your records.
CLAIM INFORMATION
First Name
Last Name
Street Address 1
Street Address 2
City
State
Zip Code
Email Address
Home Phone
Cell Phone