Carr, et al. v. Beaumont Health, et al.

Case No. 2020-181002-NZ

Circuit Court of Oakland County, Michigan

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Please remember to enter the full Notice ID exactly as it appears on your personalized Notice, (i.e. 12345678).

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If you did not receive a personalized Notice in the mail or via email, click below to complete a Claim Form.

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BEAUMONT SETTLEMENT CLAIM FORM

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.

1. CLASS MEMBER INFORMATION

Required Information:

* Required Fields
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.

If you did not receive a postcard notifying you of the Settlement, please provide the name you used at the time you received treatment from Beaumont, the year or years in which you received treatment at Beaumont, and check the box next to the location of the facility at which you received treatment from Beaumont.

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FACILITY OF TREATMENT

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.

Date Description Dollar Amount

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).

Accepted file types are: PDF, TIF, JPG, GIF, PNG. Other file types will be rejected. Please confirm in the grid below that your file has been successfully uploaded.

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    Date Description Dollar Amount

    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).

    Accepted file types are: PDF, TIF, JPG, GIF, PNG. Other file types will be rejected. Please confirm in the grid below that your file has been successfully uploaded.

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      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:

      Attestation

      Unreimbursed Extraordinary Expenses

      Date Description Dollar Amount

      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.

      Accepted file types are: PDF, TIF, JPG, GIF, PNG. Other file types will be rejected. Please confirm in the grid below that your file has been successfully uploaded.

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        D. Supporting Documentation

        Accepted file types are: PDF, TIF, JPG, GIF, PNG. Other file types will be rejected. Please confirm in the grid below that your file has been successfully uploaded.

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          E. Certification

          I declare under penalty of perjury under the laws of the United States and the State of that the information supplied in this Claim Form by the undersigned is true and correct to the best of my belief and recollection, and that this form was executed on the date set forth below.

          I understand that I may be asked to provide supplemental information by the Claims Administrator or Claims Referee before my claim will be considered complete and valid.

          Your Claim Form has been submitted successfully.

          HOWEVER, it appears one or more of the documents you uploaded were not successfully received. Please see below for which file(s) had errors and log back in to your existing Claim online to re-upload your document(s). Alternatively, you can send your documents with your Submitted Claim ID to the Settlement Administrator by email to: info@BeaumontSettlement.com.

          Please print this page for your records.

          Your Claim Details

          Submitted Claim ID:
          Confirmation Code:
          You will need the above Submitted Claim ID and Confirmation Code if you would like to edit your Claim at a later time, so please print this page for your records.
          CLAIM INFORMATION
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          Address 1
          Address 2
          City
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          Province
          ZIP
          Postal Code
          Country
          Email Address
          Phone
          Signature
          Date

          If you have any questions regarding your Claim, please provide the Submitted Claim ID listed above and email us at info@BeaumontSettlement.com

          Click here to edit your Claim.