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claim form - jul '21

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Rev. Jul '21 Email: [email protected] // Fax: 800-977-5591 // Mail to: Claims Dept., PO Box 1073, Point Pleasant Beach, NJ 08742 Be sure to fill out ALL fields for EVERY Manufacturer you claim. Failure to do so may result in a Manufacturer Denial

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Page 1: Claim Form - Jul '21

Rev. Jul '21 Email: [email protected] // Fax: 800-977-5591 // Mail to: Claims Dept., PO Box 1073, Point Pleasant Beach, NJ 08742

Be sure to fill out ALL fields for EVERY Manufacturer you claim. Failure to do so may result in a Manufacturer Denial

Page 2: Claim Form - Jul '21

Rev. Jul '21 Email: [email protected] // Fax: 800-977-5591 // Mail to: Claims Dept., PO Box 1073, Point Pleasant Beach, NJ 08742

Be sure to fill out ALL fields for EVERY Manufacturer you claim. Failure to do so may result in a Manufacturer Denial

Page 3: Claim Form - Jul '21

Rev. Jul '21 Email: [email protected] // Fax: 800-977-5591 // Mail to: Claims Dept., PO Box 1073, Point Pleasant Beach, NJ 08742

Be sure to fill out ALL fields for EVERY Manufacturer you claim. Failure to do so may result in a Manufacturer Denial

Page 4: Claim Form - Jul '21

Rev. Jul '21 Email: [email protected] // Fax: 800-977-5591 // Mail to: Claims Dept., PO Box 1073, Point Pleasant Beach, NJ 08742

Be sure to fill out ALL fields for EVERY Manufacturer you claim. Failure to do so may result in a Manufacturer Denial

Page 5: Claim Form - Jul '21

(If you combined the information on the previous page(s), pleaseidentify which Manufacturers apply to which addresses below:)

View and Learn More Here: HBArebates.com/AP

Rev. Jul '21 Email: [email protected] // Fax: 800-977-5591 // Mail to: Claims Dept., PO Box 1073, Point Pleasant Beach, NJ 08742

Address or Lot/Block City & State Completed Date


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