Settlement Class Member Affirmation. By submitting this Claim Form you affirm under penalty of perjury that, to the best of your knowledge, the Player ID(s) and email address(es) listed above are yours.
Settlement Class Member Affirmation. I declare under penalty of perjury that the information supplied in this claim form is true and correct. I authorize the Settlement Administrator to contact me, using the contact information set forth above, to obtain any necessary supplemental information. By submitting this Claim Form, I certify that any documentation that I have submitted in support of my Claim consists of unaltered documents in my possession. Please include your name in both the Signature and Printed Name fields below. Signature: Print Name: Date: If your data was accessed in the 2020 Data Security Incident involving Xxxxxx X. Xxxxxxxxx & Co. and Xxxxxxxxx Xxxxxxx Services, Inc., you may be eligible for a CASH PAYMENT or other benefits under a class action settlement. A proposed settlement has been reached in a class action lawsuit concerning a Data Security Incident perpetrated against Defendants Xxxxxx X. Xxxxxxxxx Co. (“AJG”) and Xxxxxxxxx Xxxxxxx Services, Inc. (“GB,” and collectively with AJG, “Defendants”). Between June 3, 2020 and September 26, 2020, an unknown party accessed or acquired data contained within certain segments of Defendants’ network during a criminal ransomware attack (the “Data Security Incident”). The Settlement would resolve a lawsuit in which Plaintiffs allege that the Data Security Incident exposed individuals’ personal identifying information (“PII”) and personal health information (“PHI”), including some combination of names; Social Security numbers and tax identification numbers; driver’s license, passport and other government identification numbers; dates of birth; usernames and passwords; employee identification numbers; financial account and credit card information; and/or electronic signatures, as well as medical treatment, claim, diagnosis, medication or other medical information; health insurance information; medical records or account numbers; and/or biometric information. Defendants deny all claims of wrongdoing or liability that Plaintiffs, Settlement Class Members, or anyone else have asserted in this Litigation or may assert in the future based on the conduct alleged in the complaint. The Settlement offers payments and financial account monitoring services to members of the Settlement Class. Settlement Class Members can claim the following Settlement Benefits:
Settlement Class Member Affirmation. By submitting this Claim Form and checking the box below, I declare that I received notification from Insurance Technologies Corp. and/or Zywave, Inc. that I have been identified as a potential Settlement Class Member. As I have submitted claims of losses due to the Data Breach, I declare that I suffered these losses. I understand that my Claim and the information provided above will be subject to verification. I also understand that I may not be entitled to recover under this Settlement if I am employed by and/or affiliated with the Judge or Magistrate presiding over this action, and/or am employed by the Defendants or anyone acting on their behalf. By submitting this Claim Form, I certify that any documentation that I have submitted in support of my Claim consists of unaltered documents in my possession. ☐ Yes, I understand that my failure to check this box may render my Claim null and void. Please include your name in both the Signature and Printed Name fields below. Signature: MM DD YY Printed Name:
Settlement Class Member Affirmation. By submitting this Claim Form and checking the box below, I declare that I received notification from Xxxx that I have been identified as a potential Settlement Class Member. As I have submitted claims of losses due to the Data Breach, I declare that I suffered these losses. I understand that my Claim and the information provided above will be subject to verification. I also understand that I may not be entitled to recover under this Settlement if I am employed by and/or affiliated with the Judge or Magistrate presiding over this action, and/or am employed by the Defendant or anyone acting on its behalf. Please include your name in both the Signature and Printed Name fields below. Signature: Date: – – MM DD YY Printed Name: ◼ ◼ ◼ ◼
Settlement Class Member Affirmation. By submitting this Claim Form and checking the box below, I declare that I received notification from the Defendant that I have been identified as a potential Settlement Class Member. As I have submitted claims of losses due to the Data Breach, I declare that I suffered these losses. I understand that my claim and the information provided above will be subject to verification. I also understand that I may not be entitled to recover under this Settlement if I am employed by and/or affiliated with the Judge presiding over this action, and/or am employed by the Defendant or anyone acting on their behalf. By submitting this Claim Form, I certify that any documentation that I have submitted in support of my claim consists of unaltered documents in my possession. ☐ Yes, I understand that my failure to check this box may render my claim null and void. Please provide your name in both the Signature and Printed Name fields below and date your signature below. Signature: Date: – – MM DD YY Printed Name: SUPERIOR COURT OF THE STATE OF WASHINGTON IN AND FOR THE COUNTY OF XXXX
Settlement Class Member Affirmation. I declare under penalty of perjury that the information supplied in this claim form is true and correct. I authorize the Settlement Administrator to contact me, using the contact information set forth above, to obtain any necessary supplemental information. By submitting this Claim Form, I certify that any documentation that I have submitted in support of my Claim consists of unaltered documents in my possession. Please include your name in both the Signature and Printed Name fields below. Signature: Print Name: _________________________________ Date:
Settlement Class Member Affirmation. I declare under penalty of perjury that the information supplied in this claim form is true and correct. I authorize the Settlement Administrator to contact me, using the contact information set forth above, to obtain any necessary supplemental information. By submitting this Claim Form, I certify that any documentation that I have submitted in support of my Claim consists of unaltered documents in my possession. □Yes, I understand that my failure to check this box may render my Claim null and void. Please include your name in both the Signature and Printed Name fields below. Signature: Print Name: _________________________________ Date: IN ORDER TO BE VALID, THIS CLAIM FORM MUST BE MAILED BY OR RECEIVED ONLINE AT [INSERT WEBSITE] NO LATER THAN [CLAIMS DEADLINE]. XXXXXXX XXXX and XXXXXXXXXX XXXXXXX, on behalf of themselves and all others similarly situated, Plaintiffs,
