Common use of Claim Information Clause in Contracts

Claim Information. If you need additional space to complete this form, please attached additional pages, and clearly identify by ques- tion number which question(s) you are answering on your attached pages. 1. Please identify the address of the building which contains or contained one or more Pella ProLine Casement Window(s) for which this claim applies, if different from the above: Mailing Address, including apartment, unit or box number City State Zip Code a. Type of Structure: Single Family Home Apartment Condo Commercial Other: b. Number of units, if not a single family home: 2. Identify the number of Pella ProLine Casement Window(s) installed. Please attach whatever documentation you have establishing the number of Pella ProLine Casement Window(s) that are/were installed. Pella’s name may appear on the knob of the window crank. The following questions seek information and documentation establishing that you meet the requirements to receive benefits under the Settlement. You will need to produce documentation sufficient to establish these items in order to receive benefits under the Settlement. 3. If known, please identify the purchase date of your Pella ProLine Casement Window(s) identified above and from whom the windows were purchased. Include all purchase order numbers, if known. a. Date of purchase – – MM DD YYYY b. From whom the windows were purchased (Individual or Business) c. Purchase order numbers (if known) Purchase Order 1 Purchase Order 2 Purchase Order 3 02-CA5163 K4112 v.00 00.00.0000

Claim Information. If you need additional space to complete this form, please attached additional pages, and clearly identify by ques- tion question number which question(s) you are answering on your attached pages. 1. Please identify the address of the building which contains or contained one or more Pella ProLine Casement Window(s) for which this claim applies, if different from the above: Mailing Address, including apartment, unit or box number City State Zip Code a. Type of Structure: Single Family Home Apartment Condo Commercial Other: b. Number of units, if not a single family home: 2. Identify the number of Pella ProLine Casement Window(sWindows(s) installed. Please attach whatever documentation you have establishing the number of Pella ProLine Casement Window(s) Windows that are/were installed. Pella’s name may appear on the knob of the window crank. The following questions seek information and documentation establishing that you meet the requirements to receive Arbitration and/or benefits under the Settlement. You will need to produce documentation sufficient to establish these items in order to receive Arbitration and/or benefits under the Settlement. 3. If known, please identify the purchase date of your Pella ProLine Casement Window(s) identified above and from whom the windows were purchased. Include all purchase order numbers, if known. a. Date of purchase – – MM DD YYYY b. From whom the windows were purchased (Individual or Business) c. Purchase order numbers (if known) Purchase Order 1 Purchase Order 2 Purchase Order 3 02-CA5163 K4112 K4092 v.00 00.00.0000 4. If known, please identify the date of installation of your Pella ProLine Casement Window(s) identified above. If not known, please identify the date your home was built. Installation Date: Date Home was built: – – OR – – MM DD YYYY MM DD YYYY 5. If available, please provide the glass etch information for each window. This information is located on the glass in one of the corners of each window.

Claim Information. If you need additional space to complete this form, please attached additional pages, and clearly identify by ques- tion number which question(s) you are answering on your attached pages. 1. Please identify the address of the building which contains or contained one or more Pella ProLine Casement Window(s) for which this claim applies, if different from the above: Mailing Address, including apartment, unit or box number City State Zip Code a. Type of Structure: Single Family Home Apartment Condo Commercial Other: b. Number of units, if not a single family home: 2. Identify the number of Pella ProLine Casement Window(s) installed. Please attach whatever documentation you have establishing the number of Pella ProLine Casement Window(s) that are/were installed. Pella’s name may appear on the knob of the window crank. The following questions seek information and documentation establishing that you meet the requirements to receive benefits under the Settlement. You will need to produce documentation sufficient to establish these items in order to receive benefits under the Settlement. 3. If known, please identify the purchase date of your Pella ProLine Casement Window(s) identified above and from whom the windows were purchased. Include all purchase order numbers, if known. a. Date of purchase – – MM DD YYYY b. From whom the windows were purchased (Individual or Business) c. Purchase order numbers (if known) Purchase Order 1 Purchase Order 2 Purchase Order 3 02-CA5163 K4112 v.00 00.00.000000.00.0000 QUESTIONS? Call 0-000-000-0000 or visit xxx.XxxxxxXxxxxxxxxx.xxx

Claim Information. If you need additional space to complete this form, please attached additional pages, and clearly identify by ques- tion question number which question(s) you are answering on your attached pages. 1. Please identify the address of the building which contains or contained one or more Pella ProLine Casement Window(s) for which this claim applies, if different from the above: Mailing Address, including apartment, unit or box number City State Zip Code a. Type of Structure: Single Family Home Apartment Condo Commercial Other: b. Number of units, if not a single family home: 2. Identify the number of Pella ProLine Casement Window(sWindows(s) installed. Please attach whatever documentation you have establishing the number of Pella ProLine Casement Window(s) Windows that are/were installed. Pella’s name may appear on the knob of the window crank. The following questions seek information and documentation establishing that you meet the requirements to receive Arbitration and/or benefits under the Settlement. You will need to produce documentation sufficient to establish these items in order to receive Arbitration and/or benefits under the Settlement. 3. If known, please identify the purchase date of your Pella ProLine Casement Window(s) identified above and from whom the windows were purchased. Include all purchase order numbers, if known. a. Date of purchase – – MM DD YYYY b. From whom the windows were purchased (Individual or Business) c. Purchase order numbers (if known) Purchase Order 1 Purchase Order 2 Purchase Order 3 02-CA5163 K4112 K4092 v.00 00.00.000000.00.0000 QUESTIONS? Call 0-000-000-0000 or visit xxx.XxxxxxXxxxxxxxxx.xxx 4. If known, please identify the date of installation of your Pella ProLine Casement Window(s) identified above. If not known, please identify the date your home was built. Installation Date: Date Home was xxx t: – – OR – – MM DD YYYY MM DD YYYY 5. If available, please provide the glass etch information for each window. This information is located on the glass in one of the corners of each window.