PLEASE PROVIDE THE INFORMATION LISTED BELOW. Check the box for each category of out-of-pocket expenses or lost time that you incurred as a result of the Data Incident. Please be sure to fill in the total amount you are claiming for each category and to attach documentation as described (if you provide account statements as part of proof for any part of your claim, you may mark out any unrelated transactions if you wish).
PLEASE PROVIDE THE INFORMATION LISTED BELOW. Settlement Class Members who file a valid claim will be eligible for $25, plus an additional $75 if the Settlement Class Member resided in California at the time of receiving notice from CaptureRx regarding the Data Incident. Settlement Class Members will receive only one payment. Settlement Class Payment I attest that CaptureRx notified me that my first name, last name, date of birth and prescription information was compromised during the Data Incident that took place on February 6, 2021.
PLEASE PROVIDE THE INFORMATION LISTED BELOW. Check the box for each category of expenses or lost time that you incurred as a result of the Data Incident. Please be sure to fill in the total amount you are claiming for each category and to attach documentation of the charges as described in bold type (if you are asked to provide account statements as part of proof required for any part of your claim, you may xxxx out any unrelated transactions if you wish). Please note that recovery is limited to $75 per person, and any claims made will be reduced pro rata if total aggregate claims of all class members exceed $150,000. Out-of pocket expenses incurred as a result of the Data Incident. Examples ‐ bank fees, long distance phone charges, cell phone charges (if charged by the minute), data charges (if charged based on the amount of data used), postage, or gasoline for travel. Total amount for this category: $ . If you are seeking reimbursement for out-of-pocket expenses, please attach a copy of a statement or receipt from the company that charged you, showing the amount of charges incurred. You may xxxx out any transactions that are not relevant to your claim before sending in the documentation. Reimbursement of fees paid for services or products purchased as a result of the Data incident. Examples ‐ fees for credit reports, credit monitoring, or other identity theft insurance products purchased between September 1, 2019 and [INSERT DATE OF COURT’S PRELIMINARY APPROVAL ORDER]. Total amount for this category: $ . If you are seeking reimbursement for out-of-pocket expenses, please attach a copy of a statement or receipt from the company that charged you, showing the amount of charges incurred. You may xxxx out any transactions that are not relevant to your claim before sending in the documentation. Time reimbursement for at least one full hour of time spent exclusively dealing with the Data Incident. Examples –You spent at least one full hour contacting your bank and/or implementing credit monitoring, and/or checking your statements as a result of the Data Incident. Recovery for this category is paid out at $20. Total number of hours claimed: If the time was spent online or on the telephone, briefly describe what you did, or attach a copy of any letters or emails you wrote. If the time spent related to your medical records or treatment, briefly describe what you did.
PLEASE PROVIDE THE INFORMATION LISTED BELOW. Check the box for each category of out-of-pocket expenses, fraudulent charges, or lost time that you had to pay as a result of the Data Incident. Please be sure to fill in the total amount you are claiming for each category and to attach documentation of the charges as described in bold type (if you are asked to provide account statements as part of proof required for any part of your claim, you may xxxx out any unrelated transactions if you wish).
PLEASE PROVIDE THE INFORMATION LISTED BELOW. Settlement Class Members who file a valid claim will be eligible for a Tier 1, Tier 2, OR Tier 3 award. Settlement Class Members will receive only one payment regardless of the number of credit or debit cards used by the Settlement Class Member on the Xxxxx Xxxxx website during the Data Incident. If more than one valid claim is submitted for a Settlement Class Member, the highest-valued valid claim will be processed and the remaining claims will be denied as duplicative. Please be sure to attach documentation of the charges as described in bold type (if you are asked to provide account statements as part of proof required for any part of your claim, you may mark out any unrelated transactions if you wish).
