Cash Back Claim Form

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

Member Name*

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*

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

Same as Member Information

Submitter Name*

Submitter Address*

Submitter City*

Submitter State*

Submitter Zip Code*

Submitter Phone*

Submitter Email*

Please enter the member name as it appears in cashback list