If you received a personalized notice in the mail or via email with a Notice ID and Confirmation Code, please enter the codes you were provided below.

Please remember to enter the full Notice ID exactly as it appears on your personalized Notice, (i.e. 12345678).

PERMANENT GENERAL CLASS ACTION SETTLEMENT CLAIM FORM


To submit a claim for settlement payment, you must complete the information below and sign where indicated. Failure to include this information and sign this Claim Form may result in denial of your claim(s). Once completed, you may mail the Claim Form by U.S. Mail to the address below. The Claim Form must be submitted no later than February 20, 2023. If submitted by U.S. Mail, the Claim Form must be postmarked by February 20, 2023. If submitted through the settlement website, the Claim Form must be submitted by
12:00 a.m. on February 20, 2023. Your settlement funds will be sent to you by check.

Contact Information

* Required Fields

Full legal name as it appeared on your insurance policy with Permanent General:

Mailing address or Garaging Address on your insurance policy with Permanent General:

To the best of my knowledge, I am a member of the Settlement Class and the information contained herein is true and correct.

QUESTIONS or HELP: Call 1-855-307-4277 or write to PGAC Settlement Administrator, 1650 Arch Street, Suite 2210, Philadelphia, PA 19103.

Your Claim Form has been submitted successfully.

Please print this page for your records.

Your Claim Details
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
Phone Number
Signature
Date

If you have any questions regarding your Claim, please provide the Submitted Claim ID listed above and email us at Info@ShortRateCancellationSettlement.com

Click here to edit your Claim.

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