2. PAYMENT ELIGIBILITY INFORMATION
To prepare for this section of the Claim Form, please review the Settlement Notice and the Settlement Agreement for more information on who is eligible for a payment and the nature of the expenses or losses that can be claimed.
To help us determine if you are entitled to a settlement payment, please provide as much information as possible.
A. Verification of Class Membership
You are only eligible to file a claim if you are a person to whom OFP sent notification, whether by direct written notice or substitute notice, that personal information and/or protected health information may have been or was exposed to unauthorized third parties as a result of the Data Security Incident occurring on or around April 15, 2021.
By submitting a claim and signing the certification below, you are verifying that you were notified by mail or via substitute notice of the Data Security Incident announced by OFP on or around July 20, 2021.
In addition, to allow the Claims Administrator to confirm your membership in the Class, you must provide either:
(1) The unique identifier provided in the Notice you received by postcard or e-mail;
or
(2) name and physical address you provided to OFP for healthcare related purposes.
Thus, please EITHER :
OR
(2) Provide your name and physical address you provided to OFP for healthcare related purposes:
B. Out-Of-Pocket Expenses
Check the box for each category of out-of-pocket expenses or lost time that you incurred as a result of the Data Security Incident. Please be sure to fill in the total amount you are claiming for each category and attach the required documentation as described in bold type (if you are asked to provide account statements as part of required proof for any part of your claim, you may redact unrelated transactions and all but the first four and last four digits of any account number). Please round total amounts down or up to the nearest dollar.
I. Ordinary Expenses Resulting from the Data Security Incident
Unreimbursed fees or other charges from your bank or credit card company due incurred from April 15, 2021 to September 1, 2023 (the “Claims Deadline”) due to the Data Security Incident.
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Examples: Unreimbursed overdraft fees, over-the-limit fees, late fees, or charges due to insufficient funds or interest.
Required: A copy of a bank of credit card statement or other proof of claimed fees or charges (you may redact unrelated transactions and all but the first four and last four digits of any account number)
Unreimbursed fees relating to your account being frozen or unavailable incurred from April 15, 2021to the Claims Deadline due to the Data Security Incident.
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Examples: You were charged interest by a payday lender due to card cancellation or due to an over-limit situation, or you had to pay a fee for a money order or other form of alternative payment because you could not use your debit or credit card, and these charges and payments were not reimbursed.
Required: Attach a copy of receipts, bank statements, credit card statements, or other proof that you had to pay these fees (you may redact unrelated transactions and all but the first four and last four digits of any account number).
Unreimbursed fees or other charges relating to the reissuance of your credit or debit card incurred from April 15, 2021 to the Claims Deadline due to the Data Security Incident.
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Examples: Unreimbursed fees that your bank charged you because you requested a new credit or debit card.
Required: Attach a copy of a bank or credit card statement or other receipt showing these fees (you may redact unrelated transactions and all but the first four and last four digits of any account number).
Other unreimbursed incidental telephone, internet, mileage or postage expenses directly related to the Data Security Incident incurred from April 15, 2021 to Claims Deadline due to the Data Security Incident.
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Examples: Unreimbursed long distance phone charges, cell phone charges (only if charged by the minute), or data charges (only if charged based on the amount of data used).
Required: Attach a copy of the bill from your telephone company, mobile phone company, or internet service provider that shows the charges (you may redact unrelated transactions and all but the first four and last four digits of any account number.
Credit Reports or credit monitoring charges purchased from April 15, 2021 to the Claims Deadline due to the Data Security Incident. This category is limited to services purchased primarily as a result of the Data Security Incident and if purchased from April 15, 2021 to the Claims Deadline.
To obtain reimbursement under this category, you must attest to the following:
I purchased credit reports from April 15, 2021 to the Claims Deadline, primarily due to the Data Security Incident and not for other purposes.
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Examples: The cost of a credit report(s) that you purchased after hearing about Data Security Incident.
Required: Attach a copy of a receipt or other proof of purchase for each product or service purchased (you may redact unrelated transactions).
Between one (1) and three (3) hours of documented time spent monitoring accounts or otherwise dealing with the aftermath / clean-up of the Data Security Incident from April 15, 2021 to the Claims Deadline (round down to the nearest hour and check only one box).
II. Extraordinary Expenses
If you are a member of the SSN Subclass, and have expenses related to the Data Security Incident that are more than the value or different than the type of ordinary expenses covered in the categories in Section I above, you may be entitled to compensation for your extraordinary expenses. To obtain reimbursement under this category, you must attest to the following:
The timing of the loss occurred from April 15, 2021 to the Claims Deadline and the personal information used to commit identity theft or fraud consisted of the same type of personal information that was provided to OFP prior to the Data Security Incident.
Unreimbursed fraudulent charges incurred from April 15, 2021 to the Claims Deadline due to the Data Security Incident.
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Examples: Fraudulent charges that were made on your credit or debit card account and that were not reversed or repaid even though you reported them to your bank or credit card company. Note: most banks are required to reimburse customer in full for fraudulent charges on payment cards that they issue.
Required: The bank statement or other documentation reflecting the fraudulent charges, as well as documentation reflecting the fact that the charge was fraudulent (you may redact unrelated transactions and all but the first four and last four digits of any account number). If you do not have anything in writing reflecting the fact that the charge was fraudulent (e.g., communications with your bank or a police report), please identify the approximate date that you reported the fraudulent charge, to whom you reported it, and the response.
Description of the person(s) to whom you reported the fraud:
Check this box to confirm that you have exhausted all applicable insurance policies, including but not limited to credit monitoring insurance and identity theft insurance, and that you have no insurance coverage for these fraudulent charges.
Between one (1) and eight (8) hours of documented time spent remedying actual documented fraud relating to the Data Security Incident from April 15, 2021 to the Claims Deadline (round down to the nearest hour), which has not already been claimed in Section I, above.
Examples: You spent at least one (1) full hour calling customer service lines, writing letters or e-mails, or on the internet in order to get fraudulent charges reversed or in updating automatic payment programs because your card number changed. Please note that the time that it takes to fill out this Claim Form is not reimbursable and should not be included in the total number of hours claimed.
Check all activities, below, which apply.
Please select at least one activity.
Calling bank/credit card customer service lines regarding fraudulent transactions.
Writing letters or e-mails to banks/credit card companies in order to have fraudulent transactions reversed.
Time on the internet verifying fraudulent transactions.
Time on the internet updating automatic payment programs due to new card issuance.
Calling credit reporting bureaus regarding fraudulent transactions and/or credit monitoring.
Writing letters or e-mails to credit reporting bureaus regarding correction of credit reports.
Other.
If you choose any of the options above, please provide a brief description of (1) the actions taken in response to the Data Security Incident; and (2) the time associated with each action.
To recover for lost time under this section, you must provide documentation substantiating or establishing the fraudulent activity, you must indicate the number of hours spent and provide the required description, and you must have at least one hour of lost time in order to claim this benefit.
Required: Attach a copy of any and all receipts, correspondence, confirmations, and other documents supporting the lost time claimed immediately above.
Other unreimbursed out-of-pocket expenses or losses that were incurred from April 15, 2021 to the Claims Deadline as a result of the Data Security Incident that are not accounted for in your response above.
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Examples: This category includes any other unreimbursed expenses, charges or losses that are not otherwise accounted for in your answers to the questions above, including any expenses or charges that you believe were the result of an act of identity theft.
Required: Describe the expense, why you believe that it is related to the Data Security Incident, and provide as much detail as possible about the date you incurred the expense(s) and the company or person to whom you had to pay it. Please provide copies of any receipts, police reports, or other documentation supporting your claim. For claims of reimbursement for lost time, you must provide actual documentation reflecting the amount of time you spent dealing with replacement card issues or in reversing fraudulent charges sufficient to prove how much time was spent, on what, and that the time was spent on issues related to the Data Security Incident. The Claims Administrator may contact you for additional information before processing your claim.
Check this box to confirm that you have exhausted all credit monitoring insurance and identity theft insurance you might have for these out-of-pocket expenses or losses before submitting this Claim Form.
III. Credit Monitoring
All Settlement Class Members who submit a valid claim are eligible to receive two (2) years of credit monitoring services and identity theft insurance (“Credit Monitoring Services”) provided by IDX.
Do you wish to sign up for free Credit Monitoring Services through IDX?
Yes, I want to sign up to receive free Credit Monitoring Services.
If you select “yes” for this option, you will need to follow instructions and use an activation code that you receive after the Settlement is final. Credit Monitoring Services will not begin until you use your activation code to enroll. Activation instructions will be provided to your email address or, if you do not have an email address, to your home address.