Common use of Required Affirmations Clause in Contracts

Required Affirmations. IF SUBMITTED ELECTRONICALLY: 🞎 I agree that, by submitting this Claim Form, the information in this Claim Form is true and correct to the best of my knowledge. I understand that my Claim Form may be subject to audit, verification, and Court review. I am aware that I can obtain a copy of the full notice and Settlement Agreement at www.[xxxx].com or by writing the Settlement Administrator at the email address [xxxx]@[xxxx].com or the postal address [Address], [City], [State] [Zip Code]. Checking this box constitutes my electronic signature on the date of its submission. Dated: Signature: • A Settlement with a $1,670,000 cash fund has been reached in a class action lawsuit claiming that Change Healthcare Resources, LLC, under the brand My Advocate, calling on behalf of Blue Cross Blue Shield of North Carolina (“Defendants”), sent prerecorded voice messages to wireless telephone numbers without consent of the recipients in violation of the Telephone Consumer Protection Act, 47 U.S.C. § 227. Defendants deny the allegations in the lawsuit and the Court has not decided who is right. • If you are a Settlement Class Member, your legal rights are affected whether you act or do not act. Read this notice carefully. DO NOTHING If you do nothing but have been identified in Defendants’ records and have received a mailed notice about the Settlement, you will automatically receive a payment from the Settlement Fund and will give up your right to bring your own lawsuit against Defendants about the claims in this case. If you do nothing but have not been identified in Defendants’ records or have not received a mailed notice about the Settlement, you will not receive a payment from the Settlement Fund and will give up your right to bring your own lawsuit against Defendants about the claims in this case. MAKE A CLAIM If you have not been identified in Defendants’ records or have not received a mailed notice about the Settlement, you may make a claim to receive a payment from the Settlement Fund. If you have been identified in Defendants’ records and have received a mailed notice about the Settlement, you will automatically receive a payment from the Settlement Fund without making a claim. EXCLUDE YOURSELF You may request to be excluded from the Settlement. If you do, you will not receive a payment from the Settlement Fund but will not give up your right to bring your own lawsuit against Defendants about the claims in this case. OBJECT Write to the Court if you do not like the Settlement. GO TO A HEARING Ask to speak in Court about the fairness of the Settlement. • These rights and options—and the deadlines to exercise them—are explained in this notice. • The Court in charge of this case still must decide whether to approve the Settlement. If it does, and after any appeals are resolved, payments will be distributed as specified. Please be patient.

Required Affirmations. IF SUBMITTED ELECTRONICALLY: 🞎 I agree that, by submitting this Claim Form, the information in this Claim Form is true and correct to the best of my knowledge. I understand that my Claim Form may be subject to audit, verification, and Court review. I am aware that I can obtain a copy of the full notice and Settlement Agreement at www.[xxxx].com or by writing the Settlement Administrator at the email address [xxxx]@[xxxx].com or the postal address [Address], [City], [State] [Zip Code]. Checking this box constitutes my electronic signature on the date of its submission.IF SUBMITTED BY U.S. MAIL: I agree that, by submitting this Claim Form, the information in this Claim Form is true and correct to the best of my knowledge. I understand that my Claim Form may be subject to audit, verification, and Court review. I am aware that I can obtain a copy of the full notice and Settlement Agreement at www.[xxxx].com or by writing the Settlement Administrator at the email address [xxxx]@[xxxx].com or the postal address [Address], [City], [State] [Zip Code]. Dated: Signature:Settlement Administrator Address (where to send the completed form if submitting by mail): Health Insurance Associates TCPA Settlement, c/o , [Address], [City], [State] [Zip Code]. A court authorized this notice. You are not being sued. This is not a solicitation from a lawyer. • A Settlement withCall records indicate that you may be affected by a $1,670,000 cash fund has been reached inSettlement1 of a class action lawsuit claiming that Change Healthcare Resources, LLC, under the brand My Advocate, calling on behalf of Blue Cross Blue Shield of North CarolinaDefendant Health Insurance Associates LLC (“DefendantHealth Insurance Associatess”), sent prerecorded voice messages to wireless telephone numbers without consent of the recipients in violation of) violated a federal law called the Telephone Consumer Protection AcAct (“TCPA”) when telemarketing vendor Leads Mogul LLC (“Leads Mogul”) made telemarketing calls to individuals who were on the national Do Not Call Registryt, 47 U.S.C. § 22and those calls were forwarded to Health Insurance Associates7. Defendants denyHealth Insurance Associates denies that it violated the allegations in the lawsuit and the Court has not decided who is righlawt. • If you areThe lawsuit is called Lomas and Xxxxxx v. Health Insurance Associates, LLC, Case. No 22-cv-1564. Judge Xxxx Xxxxx decided that this settlement should be a class action on behalf of a Class, or group of people that could include you, and a Settlementhas been reached affecting this Class. • The Settlement offers payments to Class Member, yourMembers who file valid Claims. • Your legal rights are affected whether you act or do not act. Read this notice carefully. DO NOTHINGYOUR LEGAL RIGHTS AND OPTIONS IN THIS SETTLEMENT: SUBMIT A CLAIM FORM If you do nothing but have been identifiedare a member of the Class, you must submit a completed Claim Form to receive a payment of approximately $100 per claimant. If the Court approves the Settlement and it becomes final and effective, and you remain in Defendants’ records and have received a mailed notice about the SettlemenClasst, you will automaticallyreceive your payment by check. EXCLUDE YOURSELF You may request to be excluded from the Settlement and if you do, you will receive no benefits from the Settlement. OBJECT Write to the Court and appear at a hearing if you do not like the Settlement. DO NOTHING You will not receive a payment from the Settlement Fundif you fail to timely submit a completed Claim Form, andyou will give up your right to bring your own lawsuit against DefendantsHealth Insurance Associates about the claims in this case. If you do nothing but have not been identified in Defendants’ records or have not received a mailed notice about the Settlement, you will not receive a payment from the Settlement Fund and will give up your right to bring your own lawsuit against Defendants about the claims in this case. MAKE A CLAIM If you have not been identified in Defendants’ records or have not received a mailed notice about the Settlement, you may make a claim to receive a payment from the Settlement Fund. If you have been identified in Defendants’ records and have received a mailed notice about the Settlement, you will automatically receive a payment from the Settlement Fund without making a claim. EXCLUDE YOURSELF You may request to be excluded from the Settlement. If you do, you will not receive a payment from the Settlement Fund but will not give up your right to bring your own lawsuit against Defendants about the claims in this case. OBJECT Write to the Court if you do not like the Settlement. GO TO A HEARING Ask to speak in Court about the fairness of the Settlement. • These rights and options—and the deadlines to exercise them—are explained in this notic. 1 Capitalized terms herein have the same meanings as those defined in the Settlement Agreemente. • The Court in charge of this case still musthas to decide whether to approve the Settlement. If it does, and after any appeals are resolved, paymentsbenefits will be distributed as specifieto those who submit qualifying Claim Formsd. Please be patient. BASIC INFORMATION PAGE 3 1. Why is there a notice? 2. What is this litigation about? 3. What is the Telephone Consumer Protection Act? 4. Why is this a class action? 5. Why is there a settlement? WHO IS PART OF THE SETTLEMENT PAGE 4 6. Who is included in the Settlement? 7. What if I am not sure whether I am included in the Settlement? THE SETTLEMENT BENEFITS PAGE 4 8. What does the Settlement provide? 9. How do I file a Claim? 10. When will I receive my payment? EXCLUDING YOURSELF FROM THE SETTLEMENT PAGE 5 11. How do I get out of the Settlement? 12. If I do not exclude myself, can I sue Defendant for the same thing later? 13. What am I giving up to stay in the Class? 14. If I exclude myself, can I still get a payment? 15. Do I have a lawyer in the case? 16. Should I get my own lawyer? 17. How will the lawyers be paid? OBJECTING TO THE SETTLEMENT PAGE 6 18. How do I tell the Court I do not like the Settlement? 19. What is the difference between objecting and asking to be excluded? THE FINAL APPROVAL HEARING PAGE 7 20. When and where will the Court decide whether to approve the Settlement? 21. Do I have to attend the hearing? 22. May I speak at the hearing? IF YOU DO NOTHING PAGE 7 23. What happens if I do nothing at all? GETTING MORE INFORMATION PAGE 7 24. How do I get more information? 1. Why was this notice issued? 2. What is this lawsuit about? 3. What is a class action and who is involved? 4. Why is this lawsuit a class action? 5. Why is this there a settlement?.

Required Affirmations. IF SUBMITTED ELECTRONICALLY: 🞎 I agree that, by submitting this Claim Form, the information in this Claim Form is true and correct to the best of my knowledge. I understand that my Claim Form may be subject to audit, verification, and Court review. I am aware that I can obtain a copy of the full notice and Settlement Agreement at www.[xxxx].com or by writing the Settlement Administrator at the email address [xxxx]@[xxxx].com or the postal address [Address], [City], [State] [Zip Code]. Checking this box constitutes my electronic signature on the date of its submission.IF SUBMITTED BY U.S. MAIL: I agree that, by submitting this Claim Form, the information in this Claim Form is true and correct to the best of my knowledge. I understand that my Claim Form may be subject to audit, verification, and Court review. I am aware that I can obtain a copy of the full notice and Settlement Agreement at www.[xxxx].com or by writing the Settlement Administrator at the email address [xxxx]@[xxxx].com or the postal address [Address], [City], [State] [Zip Code]. Dated: Signature:Settlement Administrator Address (where to send the completed form if submitting by mail): Cardinal Financial TCPA Settlement, c/o , [Address], [City], [State] [Zip Code]. A court authorized this notice. You are not being sued. This is not a solicitation from a lawyer. • A Settlement withCall records indicate that you may be affected by a $1,670,000 cash fund has been reached inSettlement1 of a class action lawsuit claiming that Change Healthcare Resources, LLC, under the brand My Advocate, calling on behalf of Blue Cross Blue Shield of North CarolinaDefendant Cardinal Financial (“DefendantCardinal Financials”), sent prerecorded voice messages to wireless telephone numbers without consent of the recipients in violation of) violated a federal law called the Telephone Consumer Protection Act, 47 U.S.C. § 227. Defendants deny the allegations in the lawsuitAct (“TCPA”) and the Court has not decided who is righFlorida Telephone Solicitations Act (“FTA”). Cardinal Financial denies that it violated the lawt. • If you areThe lawsuit is called Xxxxx Xxxxxx x. Xxxxxxxx Financial Company, Limited Partnership, Case. No 21-cv-2744. Judge Xxxx Xxxxxxx decided that this settlement should be a class action on behalf of a Class, or group of people that could include you, and a Settlementhas been reached affecting this Class. • The Settlement offers payments to Class Member, yourMembers who file valid Claims. • Your legal rights are affected whether you act or do not act. Read this notice carefully. DO NOTHINGYOUR LEGAL RIGHTS AND OPTIONS IN THIS SETTLEMENT: SUBMIT A CLAIM FORM If you do nothing but have been identifiedare a member of the Class, you must submit a completed Claim Form to receive a payment of up to $51 per claimant, less any approved fees and costs. If the Court approves the Settlement and it becomes final and effective, and you remain in Defendants’ records and have received a mailed notice about the SettlemenClasst, you will automaticallyreceive payment by check. EXCLUDE YOURSELF You may request to be excluded from the Settlement and if you do, you will receive no benefits from the Settlement. OBJECT Write to the Court and appear at a hearing if you do not like the Settlement. DO NOTHING You will not receive a payment from the Settlement Fundif you fail to timely submit a completed Claim Form, andyou will give up your right to bring your own lawsuit against DefendantsCardinal Financial about the claims in this case. If you do nothing but have not been identified in Defendants’ records or have not received a mailed notice about the Settlement, you will not receive a payment from the Settlement Fund and will give up your right to bring your own lawsuit against Defendants about the claims in this case. MAKE A CLAIM If you have not been identified in Defendants’ records or have not received a mailed notice about the Settlement, you may make a claim to receive a payment from the Settlement Fund. If you have been identified in Defendants’ records and have received a mailed notice about the Settlement, you will automatically receive a payment from the Settlement Fund without making a claim. EXCLUDE YOURSELF You may request to be excluded from the Settlement. If you do, you will not receive a payment from the Settlement Fund but will not give up your right to bring your own lawsuit against Defendants about the claims in this case. OBJECT Write to the Court if you do not like the Settlement. GO TO A HEARING Ask to speak in Court about the fairness of the Settlement. • These rights and options—and the deadlines to exercise them—are explained in this notice. • The Court in charge of this case still musthas to decide whether to approve the Settlement. If it does, and after any appeals are resolved, paymentsbenefits will be distributed as specifieto those who submit qualifying Claim Formsd. Please be patient 1 Capitalized terms herein have the same meanings as those defined in the Settlement Agreement. BASIC INFORMATION PAGE 3 1. Why is there a notice? 2. What is this litigation about? 3. What is the Telephone Consumer Protection Act? 4. Why is this a class action? 5. Why is there a settlement? WHO IS PART OF THE SETTLEMENT. PAGE 4 6. Who is included in the Settlement? 7. What if I am not sure whether I am included in the Settlement? THE SETTLEMENT BENEFITS. PAGE 4 8. What does the Settlement provide? 9. How do I file a Claim? 10. When will I receive my payment? 11. How do I get out of the Settlement? 12. If I do not exclude myself, can I sue Defendant for the same thing later? 13. What am I giving up to stay in the Class? 14. If I exclude myself, can I still get a payment? THE LAWYERS AND THE PLAINTIFF REPRESENTING YOU. PAGE 6 15. Do I have a lawyer in the case? 16. Should I get my own lawyer? 17. How will the lawyers be paid? OBJECTING TO THE SETTLEMENT PAGE 6 18. How do I tell the Court I do not like the Settlement? 19. What is the difference between objecting and asking to be excluded? THE FINAL APPROVAL HEARING. PAGE 7 20. When and where will the Court decide whether to approve the Settlement? 21. Do I have to attend the hearing? 22. May I speak at the hearing? IF YOU DO NOTHING. PAGE 7 23. What happens if I do nothing at all? GETTING MORE INFORMATION. PAGE 7 24. How do I get more information? 1. Why was this notice issued? 2. What is this lawsuit about? 3. What is a class action and who is involved? 4. Why is this lawsuit a class action? 5. Why is this there a settlement?.