REMINDER CHECKLIST. Sign the above release and certification. If this Claim Form is being made on behalf of joint claimants, then both must sign.
REMINDER CHECKLIST. Please sign this Claim Form. 2. DO NOT HIGHLIGHT THE CLAIM FORM OR YOUR SUPPORTING DOCUMENTATION.
REMINDER CHECKLIST. If you desire an acknowledgment of receipt of your Claim Form, please send it Certified
REMINDER CHECKLIST. Before finalizing your claim form, please consult the below checklist: Review the claim form in detail to ensure all required information has been entered. Review the claim form and Mandatory Evidence requirements (located on pages 1-2) and Injury-specific evidence (located on pages 12-16) to ensure you have provided all complete and necessary records with your claim form. Make a copy of the claim form and all evidence, for your records. If you move or your contact information changes, it is your responsibility to notify the Claims Administrator of your updated contact information. Finally, please sign and date the claim form. Please sign only the appropriate lines. Signatures on all lines may not be required. OxyContin®/OxyNEO® User Claimant’s (or Executor/Guardian) Signature Printed Name of OxyContin®/OxyNEO® User Claimant (or Executor/Guardian) Signature of OxyContin®/OxyNEO® User Claimant’s Lawyer (if any) Printed Name of OxyContin®/OxyNEO® User Claimant’s Lawyer (if any) All Forms and documents must be postmarked no later than June 27, 2024 and mailed to: Claims Administrator P.O. Box 3355 London, Ontario All Forms must be submitted online and all documents must be sent via email attachment to xxxxxxxxx@xxxxxxxxx.xxx
REMINDER CHECKLIST. Please check and make sure you answered all the questions on the claim form as requested.
REMINDER CHECKLIST. 1. Complete all sections of this Claim Form. 2. Sign and date the Claim Form in Section 3.
REMINDER CHECKLIST. 1. Keep copies of the completed Claim Form and documentation for your own records.
2. If your address changes or you need to make a correction to the address on this claim form, please visit the settlement administration website at [WEBSITE] and complete the Update Contact Information form or send written notification of your new address. Make sure to include your Settlement Claim ID and your phone number in case we need to contact you in order to complete your request.
3. If you need to supplement your claim submission with additional documentation, please visit the settlement administration website at [WEBSITE] and provide these documents by completing the Secure Contact Form.
4. For more information, please visit the settlement administration website at [WEBSITE]or call the Settlement Administrator at [TELEPHONE#]. Please do not call the Court or the Clerk of the Court for additionalinformation.
REMINDER CHECKLIST. 1. Please sign the release and certification below. If this Proof of Claim form is being submitted on behalf of joint claimants, then both must sign.
2. Remember to attach only copies of acceptable supporting documentation.
3. Please do not highlight any portion of the Proof of Claim form or any supporting documents.
4. Do not send original stock certificates or documentation. These items cannot be returned to you by the Settlement Administrator.
5. Keep copies of the completed Proof of Claim form and documentation for your own records.
6. You will not receive confirmation of receipt of your Proof of Claim. If confirmation is desired, please send your Proof of Claim Certified Mail, Return Receipt Requested.
7. If your address changes in the future, or if this Proof of Claim was sent to an old or incorrect address, please send the Settlement Administrator written notification of your new address. If you change your name, please inform the Settlement Administrator.
8. If you have any questions or concerns regarding your Proof of Claim form, please contact the Settlement Administrator at the above address or call 000- 000-0000 or visit xxx.xxxxxxxxxxxxxxxxxxxxxxxxx.xxx. Must be Postmarked No Later Than: , 201_ Please Type or Print
PART I: CLAIMANT IDENTIFICATION _ Beneficial Owner’s Name(s) (First, Middle, Last) _ Record Holder’s Name(s) (if different from beneficial owner listed above) _ Street Address (Line 1) _ Street Address (Line 2) City State Postal / Zip Code Foreign Province Foreign Country Social Security Number or Taxpayer Identification Number (if U.S. Citizen / Resident) Country / Area _(work) Telephone Number Code Country / Area Code _ (home/cell) Telephone Number _ Email Address (optional) Check One: Estate _ Other _ (specify)
REMINDER CHECKLIST. Keep copies of the completed Claim Form and documentation for your own records. • If your address changes or you need to make a correction to the address on this Claim Form, please visit the Settlement website at [insert Settlement Website URL] and complete the Update Contact Information form or send written notification of your new address. Make sure to include your Settlement Claim ID and your phone number in case we need to contact you in order to complete your request. • Please do not provide any sensitive documents that may contain personal information via email to the Settlement Administrator. If you need to supplement your claim submission with additional documentation, please visit the Settlement website at [insert Settlement Website URL] and provide these documents by completing the Secure Contact Form or by mail. • For more information, please visit the settlement website at [insert Settlement Website URL], or call the Settlement Administrator at 1-XXX-XXX-XXXX. Please do not call the Court or the Clerk of the Court for additional information.
