Gas Connect - Customer Assistance Fund Form

PLEASE READ CLAIM FORM CAREFULLY BEFORE FILLING IN INFORMATION.

CLAIMANT INFORMATION

Full Name:

Email Address:

Address:

Cross Street:

City/Town:

State:

Zip Code:

Business Name:

Home Phone:

Please enter a valid value in the format of 999-999-9999

Business Phone:

Please enter a valid value in the format of 999-999-9999

Account Number:

Please enter a valid value in the format of 99999-99999

Date Gas Application for Service was Submitted:

Please enter a valid value in the format of MM-DD-YYYY

Incident Information

Address of Incident:

City/Town:

Date Range of Loss:

From Date:

Please enter a valid value in the format of MM-DD-YYYY

To Date:

Please enter a valid value in the format of MM-DD-YYYY

Description of Incident: Briefly describe the events causing the damage/loss.

List all damages claimed: Please include make, model number, and date of original purchase for EACH item claimed. If claim includes a purchase, upload supporting documentation of all damages including, but not limited to, permit fees.

Documentation

Upload Supporting Documentation:

FRAUD STATEMENT REQUIRED BY THE STATE OF NEW YORK: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES A STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME.

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Gas Connect - Customer Assistance Fund Form