TIANA CRUZ-SANTIAGO v. AMICA MUTUAL INSURANCE COMPANY

Case No. 19-CA-006930

CIRCUIT COURT OF THE THIRTEENTH JUDICIAL CIRCUIT IN AND FOR HILLSBOROUGH COUNTY, FLORIDA

If you received a personalized notice in the mail 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).

If you are returning to a edit a claim, enter the Notice ID and Confirmation Code as they appear in the confirmation email.

OR

If you did not receive a personalized Notice in the mail, click below to complete a Claim Form.

To be considered, this Claim Form must be submitted on or before December 4, 2020.

Claim Information

Please review the address information contained below, fill in your email address, and make any necessary changes to ensure we have your correct address and type you name into the signature box.

I. ADDRESS

II. AFFIRMATION

By signing below, I submit this Claim Form.

* Required Fields

You may not change your name. If you have legally changed your name or the class member is deceased, please sub the claim and email us at info@AmicaTotalLossSettlement.com. Your email must include your Notice ID number, the original name, requested name change, a copy of your government issued identification (driver’s license or passport) and proof of the reason the name should be changed.

For name changes due to marriage or divorce please provide such as a Marriage Certificate, Order of the Court and/or Divorce Decree. For deceased class members please provide a copy of a Death Certificate and Letters Testamentary, or Letters of Administration.

DO NOT SEND ORIGINAL PAPERS THEY WILL NOT BE RETURNED

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
Street Address 2
City
State
Zip Code
Email Address
Date of Loss
Signature
Date

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

Click here to edit your Claim.