REMINDER CHECKLIST. 1. Please sign the above release and certification. If this Claim Form is being made on behalf of joint claimants, then both must sign.
REMINDER CHECKLIST. 1. Please sign this Claim Form. 2. DO NOT HIGHLIGHT THE CLAIM FORM OR YOUR SUPPORTING DOCUMENTATION.
REMINDER CHECKLIST. 1. Keep copies of the completed Claim Form and documentation for your own records.
REMINDER CHECKLIST. 6. If you desire an acknowledgment of receipt of your Claim Form, please send it Certified
REMINDER CHECKLIST. 1. Please check and make sure you answered all the questions on the claim form as requested.
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. The Claims Administrator will acknowledge receipt of your OxyContin®/OxyNEO® User Claim Form by mail within 60 days. If you do not receive an acknowledgement postcard within 60 days, please call the Claims Administrator toll free at 0 (000) 000-0000. PLEASE ENSURE THAT YOU SIGN AND DATE THIS FORM Please sign only the appropriate lines. Signatures on all lines may not be required. Date: OxyContin®/OxyNEO® User Claimant’s (or Executor/Guardian) Signature Printed Name of OxyContin®/OxyNEO® User Claimant (or Executor/Guardian) Date: Signature of OxyContin®/OxyNEO® User Claimant’s Lawyer (if any) Printed Name of OxyContin®/OxyNEO® User Claimant’s Lawyer (if any) SUBMIT YOUR CLAIM BY MAIL: All Forms and documents must be postmarked no later than June 27, 2024 and mailed to: Claims Administrator P.O. Box 3355 London, Ontario N6A 4K3 OR SUBMIT YOUR CLAIM ONLINE: All Forms must be submitted online and all documents must be sent via email attachment to xxxxxxxxx@xxxxxxxxx.xxx by no later than 5:00 p.m. Pacific Time on June 27, 2024. OR SUBMIT YOUR CLAIM BY FAX: All Forms and documents must be faxed to the Claims Administrator to 000-000-0000 by no later than 5:00 p.m. Pacific Time on June 27, 2024.
REMINDER CHECKLIST. 1. Complete all sections of this Claim Form. 2. Sign and date the Claim Form in Section 3.
REMINDER CHECKLIST. 1. Please sign the Certification section of the Proof of Claim and Release on Page 7.
REMINDER CHECKLIST. 1. Please sign the above release and declaration.
REMINDER CHECKLIST. 1. Remember to sign the above release and declaration.
