Upload Paper Claim Form or Opt Out

If you prefer not to submit an electronic Claim Form, or prefer not to mail a paper Claim Form, or prefer not to mail a paper Request for Exclusion (“Opt Out”), you may complete the below fields and upload your form directly to the Claims Administrator here:

First Name *

Last Name *

Email Address

Submission Type *

Max: 15 files (must be less than 4MB each. PDF, JPEG, JPG, PNG allowed)

E-Signature *

Date *

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Questions? Contact the Claims Administrator at info@ESGWDataSettlement.com or 888-231-9068.

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