Documented Extraordinary Expense Reimbursement. Claims under this category must be supported by an attestation and documentation substantiating the full extent of the amount claimed. The Settlement Administrator will employ heightened scrutiny in reviewing claims for benefits under this category. Settlement Class Members may submit claims for up to five thousand United States Dollars ($5,000) in compensation by submitting a valid and timely Claim Form that proves more likely than not a monetary loss or expense directly arising from identity theft or other fraud perpetuated on or against the Settlement Class Member if: (i) the loss or expense is an actual, documented, and unreimbursed monetary loss; (ii) the loss or expense was more likely than not the result of the Data Breach; (iii) the loss or expense is not already covered by the “Documented Ordinary Expense Reimbursement” category; and (iv) the Settlement Class Member made reasonable efforts to avoid, or seek reimbursement for, the loss or expense, including but not limited to exhaustion of all available credit monitoring insurance and identity theft insurance and other available insurance.
Documented Extraordinary Expense Reimbursement. 3. Do you have documents supporting that as a result of the Data Breach you experienced unreimbursed actual identity theft losses or expenses or other unreimbursed fraudulent charges other than what is included above? You may submit a claim, with supporting documentation, for up to $5,000.00 for documented unreimbursed actual identity theft losses or expenses and/or other unreimbursed fraudulent charges that resulted from the Data Breach. The total amount you can claim for these extraordinary losses and expenses is capped at $5,000.00. Please note that you may not seek reimbursement under this category for any expense that you are also seeking reimbursement for in the “Documented Ordinary Expense Reimbursement” category (Benefit 1). Yes ☐ (Proceed to the chart below) No ☐ (Skip to Benefit 3 below) Loss or Expense Type (Check all that apply) Date of Loss or Expense Amount of Loss or Expense Description of Supporting Documentation (Identify what you are attaching and why) ☐ Documented unreimbursed actual identity theft losses or expenses that are the result of the Data Breach. Example: You experienced actual identity theft as a result of the Data Breach that resulted in you incurring out-of-pocket losses or expenses that were not reimbursed. Note that for credit card and bank charges, you must provide confirmation that the charges were not reversed or credited back. ☐ Other documented unreimbursed fraudulent charges that you incurred as a result of the Data Breach. Example: You experienced a fraudulent charge as a result of the Data Breach that resulted in you incurring out-of-pocket losses or expenses that were not reimbursed. Please provide a detailed description of the losses or expenses and documentation clearly identifying In Re U.S. Vision Data Breach Litigation, Case No. 1:22-cv-06558 (CPO/SAK) (United States District Court for the District of New Jersey) Settlement with Nationwide Optometry, P.C., Nationwide Vision Center, LLC, and Sightcare, Inc., (collectively, “Nationwide-Sightcare) the loss or expense (including amount and date of the loss or expense) and supporting documentation that the loss or expense was incurred as a result of the Data Breach. Note that for credit card and bank charges, you must provide confirmation that the charges were not reversed or credited back.
