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. You may xxxx out any transactions that are not relevant to your claim before sending in the documentation. and [INSERT DATE OF COURT’S PRELIMINARY APPROVAL ORDER]. You may xxxx out any transactions that are not relevant to your claim before sending in the documentation. 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).
PLEASE PROVIDE THE INFORMATION LISTED BELOW. You must describe the unreimbursed losses claimed (including the amount of each loss), sign the attestation at the end of this Claim Form, and attach supporting documentation (if you provide account statements as part of proof required for any part of your claim, you may mark out any unrelated transactions if you wish). Documentation supporting Extraordinary Out-of-Pocket Losses can include receipts or other documentation not “self-prepared” by the Settlement Class Member that documents the costs incurred. By signing the attestation below, you are affirming that to the best of your knowledge and belief the claimed loses were more likely than not caused by the Data Incident. Description of Extraordinary Loss $ ● – – MM DD YYYY Description of Extraordinary Loss $ ● – – MM DD YYYY Description of Extraordinary Loss $ ● – – MM DD YYYY TOTAL Amount Being Claimed: $ ● □ I have attached documentation showing that the claimed loses were more likely than not caused by the Data Incident. □ Check this box to confirm that you have exhausted all applicable insurance policies, including credit monitoring insurance and identity theft insurance, and that you have no insurance coverage for these fraudulent charges. All Settlement Class Members are eligible to claim two (2) years of credit monitoring services with three bureau and at least $1,000,000.00 in identity theft insurance. Do you wish to claim 2 years of free Credit Monitoring? Yes, I want to receive free Credit Monitoring, and my email address is as follows: Email Address: If you select “YES” for this option, you will need to follow instructions and use an activation code that you receive after the Settlement is final. Credit Monitoring Protections will not begin until you use your activation code to enroll. Activation instructions will be provided to your email address. If you do not have an email address, your activation code and instructions will be sent to your home address listed on this Claim Form. Were you a Medicare beneficiary during the time period of February 12, 2023 to the present? (check one) □ Yes □ No If you are a Medicare beneficiary receiving more than $750 under this settlement, the Settlement Administrator may need to contact you for additional information related to Medicare reporting requirements. I declare under penalty of perjury and the laws of the United States and my state of residence that the information supplied in this Claim Form by the undersigned is true and correct to the best of m...
PLEASE PROVIDE THE INFORMATION LISTED BELOW. Check the box for each category of out-of-pocket expenses or lost time that you reasonably incurred/experienced as a result of the Met Opera Data Security 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 mark out any unrelated transactions if you wish). You may not claim the same out-of-pocket expenses or lost time in more than one category.
