Step 1 of 2 50% CommentsThis field is for validation purposes and should be left unchanged.This field is hidden when viewing the formHidden ClaimantID*This field is hidden when viewing the formHidden Last Name*ClaimFormNo STARLING TCPA SETTLEMENT CLAIM FORM THE CLAIM FORM MUST BE SUBMITTED OR POSTMARKED BY JULY 24, 2026 AND MUST BE FULLY COMPLETED, SIGNED, AND MEET ALL CONDITIONS OF THE SETTLEMENT AGREEMENT. Notice ID*1. My Name:* First Last 2. My Current Mailing Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code 3. Phone Number that received more than one call or text message from insurance agents Todd Henderson Insurance Agency, Inc. and/or R. Todd Henderson marketing Farmers Insurance®*4. My Current Email Address:* 5. My Current Contact Phone #:*(You may be contacted if further information is required.) 6. By signing this form, I am certifying that the following statements are true: a. I was the subscriber or primary user of the phone number listed on line 3. b. I did not visit any website to request an insurance quote from Farmers or its agents prior to receipt of the calls or text messages. c. I was not a Farmers customer at the time I received the calls or text messages or within 18 months before receiving the calls or text messages. All information provided in this Claim Form is true and correct to the best of my knowledge and belief. Signature*Date* MM slash DD slash YYYY If your Claim Form is incomplete, untimely, unsigned, or contains false information, it may be rejected. If accepted and the Settlement is approved by the Court, you will be mailed a check at the mailing address you provide above or provided payment electronically if you selected electronic payment by submitting this claim form online. This process takes time; please be patient. Questions? call +1 800-379-4946 or email [email protected]. Payment SelectionPlease select the Payment Option by which you would like to receive your payment and complete the steps as prompted. Chosen Payment Method*This field is hidden when viewing the formPayment Token*
