If you received a personalized notice in the mail or via email with a Notice ID and Confirmation Code, please enter the codes you were provided below.

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

If you received Notice of this Settlement, the Settlement Administrator identified you as a Settlement Class Member whose name, address, Social Security number, driver’s license number, state identification number, or medical information (“PII”) was potentially compromised as a result of the Data Incident that Pape-Dawson learned of on or about February 21, 2022 (“Data Security Incident”). As a member of the Settlement Class, you are eligible to complete this Claim Form to claim (1) up to $325 for (i) reimbursement for documented ordinary out-of-pocket expenses and/or (ii) up to 3 hours of lost time compensable at $25 per hour; (2) up to $4,000 for reimbursement of documented extraordinary losses; and 1 year credit monitoring through Aura with up to $1 million in reimbursement insurance coverage.

Please refer to the Settlement Notice (Long Notice) for more information on information on submitting a Claim and information on the aggregate cap on claims.

To receive any of these benefits, you must submit the Claim Form below by November 9, 2023.

Expense Reimbursement: All members of the Settlement Class who submit a Valid Claim using the Claim Form are eligible to claim reimbursement for documented ordinary out-of-pocket expenses, not to exceed $325 per member of the Settlement Class, that were incurred as a result of the Data Security Incident: Examples of reimbursable expenses incurred as a result of the Data Security Incident include 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; fees for credit reports, credit monitoring, or other identity theft insurance products purchased between February 21, 2022 to the date of the close of the Claims Period.

Time Spent Dealing With the Data Security Incident: As part of an expense reimbursement claim, you may claim up to 3 hours of lost time, at $25/hour, for time spent dealing with the effects of the Data Security Incident. This amount is subject to the $325 per member cap.

Extraordinary Expense Reimbursement: All members of the Settlement Class who have suffered a proven monetary loss and who submit a Valid Claim using the Claim Form are eligible for up to $4,000 if: (i) The loss is an actual, documented, and unreimbursed monetary loss arising from fraud or misuse; (ii) The loss from fraud or misuse was more likely than not caused by the Data Security Incident; (iii) The loss occurred between February 21, 2022 and Claims Deadline; (iv) The loss is not already covered by one or more of the examples of ordinary out-of-pocket losses listed above; and the Settlement Class Member made reasonable efforts to avoid, or seek reimbursement for, the loss, including but not limited to exhaustion of all available credit monitoring insurance and identity theft insurance.

Please read the claim form carefully and answer all questions. Failure to provide required information could result in a denial of your claim.

This Claim Form may be submitted electronically via this portal or completed and mailed to the address below. Please type or legibly print all requested information, in blue or black ink. Mail your completed Claim Form, including any supporting documentation, by U.S. mail to:

Pape-Dawson Settlement Administrator
1650 Arch Street, Suite 2210
Philadelphia, PA 19103

I. CLASS MEMBER NAME AND CONTACT INFORMATION

Provide your name and contact information below. You must notify the Claims Administrator if your contact information changes after you submit this form.

* Required Fields

II. PROOF OF CLASS MEMBERSHIP

Enter the Notice ID Number provided on your Postcard Notice or the last four digits of your Social Security Number:

III. IDENTITY THEFT PROTECTION
IV. COMPENSATION FOR LOST TIME

All members of the Settlement Class who have spent time dealing with the Data Security Incident may claim up to three (3) hours for lost time at a rate of $25.00 per hour. Any payment for lost time is included in the $325 cap per Settlement Class member (no documentation is required).

Hours claimed (up to 3 hours – check one box)

In order to receive this payment, you must describe what you did and how the claimed lost time was spent related to the Data Security Incident. Check all activities, below, which apply.

V. REIMBURSEMENT FOR ORDINARY EXPENSES

All members of the Settlement Class who submit a Valid Claim using this Claim Form are eligible for reimbursement of the following documented out-of-pocket expenses, not to exceed $325 per member of the Settlement Class, that were incurred as a result of the Data Security Incident:

Cost Type
(Fill all that apply)		 Approximate Date of Loss Amount of Loss
Examples of Supporting Third Party Documentation: Telephone bills, cell phone bills, gas receipts, postage receipts, bank account statements reflecting out-of-pocket expenses. Please note that these examples of reimbursable documented out-of-pocket losses are not meant to be exhaustive, but exemplary. You may make claims for any documented out-of-pocket losses that you believe are reasonably related to the Data Breach or to mitigating the effects of the Data Security Incident.
Examples of Supporting Documentation: Receipts or account statements reflecting purchases made for Credit Monitoring or Identity Theft Insurance Services.
Examples of Supporting Documentation: Invoices or statements reflecting payments made for professional fees/services.
VI. REIMBURSEMENT FOR EXTRAORDINARY LOSS EXPENSES

All members of the Settlement Class who submit a Valid Claim using this Claim Form are eligible for reimbursement of the following documented extraordinary loss expenses, not to exceed $4,000 per member of the Settlement Class, that were incurred as a result of the Data Security Incident. Generally, an extraordinary loss expense is unreimbursed financial loss as the direct result of financial fraud or stolen identity.

An extraordinary loss must meet the following criteria: (i) The loss is an actual, documented, and unreimbursed monetary loss arising from fraud or misuse; (ii) The loss was more likely than not caused by the Data Security Incident; (iii.) The loss occurred between February 21, 2022 and the Claims Deadline; (iv) The loss is not already covered by one or more of the ordinary loss compensation categories under Section V; and the Settlement Class Member made reasonable efforts to avoid, or seek reimbursement for, the loss, including but not limited to exhaustion of all available credit monitoring insurance and identity theft insurance.

Cost Type
(Fill all that apply)		 Approximate Date of Loss Amount of Loss

YOU MUST SUBMIT DOCUMENTATION OF YOUR EXTRAORDINARY LOSS EXPENSES.

Examples of Supporting Documentation: Bank statements, credit card statement, letters from the IRS or other tax authorities, letters from state unemployment agencies, and police reports.
VII. UPLOAD 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.

File List: No Files Selected

    VIII. PAYMENT SELECTION

    Please select one of the following payment options, which will be used should you be eligible to receive a settlement payment:

    You have successfully requested a payment. Click here if you would like to choose a different payment method.

    IX. ATTESTATION & SIGNATURE

    I swear and affirm under the laws of my state that the information I have supplied in this Claim Form is true and correct to the best of my recollection, and that this form was executed on the date set forth below.

    Your Claim Form has been updated successfully.

    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
    First Name
    Last Name
    Street Address
    Street Address 2
    City
    State
    Province
    Zip Code
    Postal Code
    Country
    Email Address
    Telephone Number
    Signature
    Date

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

    Click here to edit your Claim.

    Print Home