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Claim Form Generation

This website allows Class Members to view and print a customized Claim Form in PDF format. Please enter the information requested below and it will be printed on your Claim Form.

You must print, complete, and mail the fully completed Claim Form to make a claim. Providing the information below and printing a Claim Form does not obligate you to submit a claim in this case.

By providing the information below, you are NOT filing a claim.

For claims accruing prior to July 10, 2014, Class Members who wish to file a claim must print, complete, sign and mail the Claim Form with proof documentation (if applicable) to the Settlement Administrator with a postmark no later than January 6, 2015 in order to be considered for benefits.

For claims accruing July 10, 2014 or after, Class Members who wish to file a claim must print, complete, sign and mail the Claim Form with proof documentation (if applicable) to the Settlement Administrator within one hundred eighty (180) days of accrual.

Usefule Life Subclass Members who wish to file a Useful Life Claim must print, complete, sign and mail the Claim Form with proof of documentation (if applicable) to the Settlement Administrator with a postmark NO later than July 10, 2015 in order to be considered for benefits.

For more information about the Settlement and the claims filing process, please review the Court and Reference Documents and Class Notice.

 

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Name and Address:

First name*:
Last name*:
Company:
C/O or Attn:

U.S.:
(including U.S. territories and military addresses)


Non-U.S.:

Address1*:
Address2:
City*:
State*:
Zip*:

(Please ensure that this is the address at which you would like to receive your settlement award if your claim is approved, and/or future correspondence from the settlement administrator regarding this settlement.)

Please provide additional contact information (optional):

Daytime Telephone Number:-- 
Evening Telephone Number:-- 
Email Address:
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