Cash Back Claim Form

Please fill out the form below to submit a Cashback claim. A representative from NOVEC will contact you shortly.

Member Information

Member Name*

Please enter the member name as it appears in this list

Current Address

Current City

Current State
Current Zip Code

Current Phone

Current Email Address

Previous Address Information
Previous Address*
Previous City*
Previous State*
Previous Zip Code*
Relative or Heir to Contact.
If deceased, please add if known.
Check here if member is deceased.
Relative/Heir Name
Relationship
Surviving Spouse
Executor
Next of Kin
Relative/Heir Address
Relative/Heir City
Relative/Heir State
Relative/Heir Zip
Relative/Heir Phone
Submitter Information
Same as Member Information

Submitter Name*

Submitter Address*

Submitter City*

Submitter State*
Submitter Zip Code*

Submitter Phone*

Submitter Email*

Test

Please enter the member name as it appears in cashback list