This Claim Form should be filled out online or submitted by mail if you (1) were sent notice of the data security incident announced by Beaumont Health on or about April 17, 2020 (the “Security Incident”); and (2) had out-of-pocket expenses (including lost time) spent dealing with, or unreimbursed extraordinary monetary losses as a result of, the Security Incident. If you fill out this claim form and have a valid claim, you will be entitled to a check if the Settlement is approved.
2. PAYMENT ELIGIBILITY INFORMATION
To prepare for this section of the Claim Form, please review the
Settlement Notice and Sections 3-6 of 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 reasonably possible.
A. Verification of Class Membership
You are eligible to file a claim only if you received notice of the settlement by postcard or other publication
and your personal information was involved in the Security Incident.
By submitting a claim and signing the certification below, you are verifying that you believe you are or may be a member of the Settlement Class, and that you in fact incurred the ordinary and/or extraordinary losses identified below as a result of the Security Incident for which you have not been reimbursed.
B. Unreimbursed Ordinary Loss Resulting from the Security Incident
Beaumont will provide compensation for unreimbursed losses, up to $250, upon submission of a claim and supporting documentation Check the box for each category of out-of-pocket expenses, credit monitoring fees, or lost time that you incurred as a result of the 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 should redact unrelated transactions and all but the first four and last four digits of any account number, if you wish). Please round total amounts to the nearest dollar.
Out of pocket expenses incurred as a result of the Security Incident.
Examples: Bank fees, long distance phone charges, cell phone charges (only if charged by the minute), data charges (only if charged based on the amount of data used), postage, or gasoline for local travel.
Required: A copy of a bank or 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).
Fees for credit reports, credit monitoring, or other identity theft insurance product purchased between April 17, 2020 and June 23, 2021. The credit report, credit monitoring, or other identity theft insurance product must have been purchased in the name of the claimant identified above to be eligible for reimbursement.
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).
Up to 3 hours of lost time, at $20 per hour, spent dealing with the Security Incident. At least one full hour must have been spent dealing with the Security Incident. Round to the nearest hour and check only one box.
Examples: You spent at least one (1) full hour calling customer service lines, writing letters or emails, or on the internet in dealing with the Security Incident or researching the matter. 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.
C. Unreimbursed Extraordinary Loss Resulting from the Security Incident
If you have unreimbursed expenses related to the Security Incident that are more than the value or different than the type of ordinary expenses covered in categories described in Section B above, you may be entitled to compensation for your extraordinary expenses. Beaumont will provide compensation, up to $2,250, to each Claimant for proven, unreimbursed monetary loss that was more likely than not caused by the Security Incident, occurred between May 2019 and October 21, 2021, and Claimant made reasonable efforts to avoid, or seek reimbursement for, the loss. To obtain reimbursement under this category, you must (1) attest to the statement set forth below, (2) check the appropriate box next to the category of unreimbursed extraordinary expense claimed, (3) provide the requested detail about the expense for which reimbursement is sought, and (4) upload the required documentation:
I incurred out-of-pocket unreimbursed expenses that occurred more likely than not as a result of the Security Incident between May 2019 and October 21, 2021 other than those expenses covered by one of the categories in Section B above, and I made reasonable efforts to avoid or seek reimbursement for the loss, including exhausting all available credit monitoring insurance and identity theft insurance.
Unreimbursed Extraordinary Expenses
Unreimbursed expenses and/or fraudulent charges incurred between May 2019 and October 21, 2021 due to the Security Incident.
Examples: Unreimbursed expenses that you had to pay and fraudulent charges that were made on your credit or debit card accounts 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: Describe the expense 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. For unauthorized charges on your credit or bank accounts, please provide the credit or bank statement or other documentation reflecting the fraudulent charges, and documentation reflecting the fact that the charge was fraudulent (you should 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, please identify the approximate date that you reported the fraudulent charge, to whom you reported it, and the response. Please also provide copies of any receipts, police reports, or other documentation supporting your claim. The Claims Administrator may contact you for additional information before processing your claim.
Description of the person(s) to whom you reported the expense or charge:
Reason you believe the claimed loss was more likely than not caused by the Security Incident: