Benefits of EZ
Shield
Request for
Reimbursement
Details of
EZ
Shield
Protection
Scope of
Recoverable Losses
Has fraud been perpetrated against your EZ
Shield
-protected checks? If so, request a reimbursement packet by filling out the form below or by
contacting us
to receive the packet via complimentary overnight delivery.
Reimbursement Form
Full Name
Address
City
State
---
AL
AK
AZ
AR
AA
AE
AP
CA
CO
CT
DE
DC
FL
GA
GU
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VT
VI
VA
WA
WV
WI
WY
Zip
Phone
Email
Describe nature of fraud
Date loss Incurred
Month
01
02
03
04
05
06
07
08
09
10
11
12
Day
01
02
03
04
05
06
07
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11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2007
2008
Date loss discovered
Month
01
02
03
04
05
06
07
08
09
10
11
12
Day
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2007
2008
Involved check number(s)
Have you...?
Contacted your bank
Filed a police report
Please enter police report #
Location of loss
Has the loss involved a...?
Family member
Resident of your household
Describe damages claimed