Goetz v. Benefit Recovery Specialists, Inc.

Case No. 20 CV 550

Walworth County Wisconsin Circuit Court

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REIMBURSMENT FORM

The deadline for submitting this proof of claim form is July 29, 2022

Eligible Settlement Class Members may submit one or more Claims for reimbursement for documented Economic Losses related to the Data Breach that have not been reimbursed by IDX or other third parties, up to an aggregate total of $2,500.00 per Settlement Class Member, provided, however, that no Settlement Class Member may submit a Reimbursement Form unless said Settlement Class Member has first elected to receive and enrolled in the IDX Settlement Offering, submitted a Reimbursement Claim to IDX, IDX has denied the claim, and said Settlement Class Member has exhausted IDX’s claims process. Any Settlement Class Member whose Reimbursement Claim to IDX is rejected for failure to submit a claim within IDX’s required time period may not submit a Claim for reimbursement under this process. If a Settlement Class Member submitted a timely Reimbursement Claim to IDX and IDX denied the claim for failure to provide sufficient supporting materials, then the loss may not be claimed for reimbursement hereunder.

Additional information is contained in the Notice and the Settlement Agreement, both of which are available on this website or by calling 1-833-937-0337.

Settlement Class Members who wish to make a timely and properly supported Claim for reimbursement of Economic Losses related to the Data Breach must provide to the Settlement Administrator the information required to evaluate the claim, including: (a) the Claimant’s name and current address; (b) if applicable, a signed copy of IRS Form 14039 along with a statement under penalty of perjury that the form was submitted to the Internal Revenue Service; (c) the bills or invoices documenting the amount of the Claim and proof that the bills or invoices were paid; (d) documentation showing that the claim was submitted to IDX, denied by IDX, and that the IDX claims process was exhausted; and (e) a statement signed under penalty of perjury indicating that: (i) the Economic Losses claimed are fairly traceable to the Data Breach; and (ii) the total amount claimed has not been reimbursed by any other person or entity. Third-party documentation of Economic Losses is required to establish a Claim. Economic Losses that are compensated under this Settlement are those that are reasonable and customarily incurred when responding to the type of fraud or identity theft suffered by the Settlement Class Member from the Data Breach.

Provide Your Contact Information:
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Additional Information:

I declare under penalty of perjury that:

You may submit one or more reimbursement requests, but all of your requests cannot exceed an aggregate $2,500. Only one (1) form is needed for multiple costs incurred from the Data Breach.

AMOUNT REQUESTED:

$

Documentary proof must be submitted to support your exact claim amount.

Please provide a brief description of economic loss requested in this Claim, as well as an explanation of how such losses are related to the Data Incident. Include the name of the healthcare provider where you received services and the approximate date of such services.

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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    Your claim will be submitted to the Settlement Administrator for review. If your Reimbursement Form is incomplete, untimely, or contains false information, it may be rejected by the Settlement Administrator. If your claim is approved, you will be mailed a check at the street address you provide. This process takes time; please be patient.

    Fill Out and Sign the Following Attestation:

    I declare under penalty of perjury under the laws of the United States that I am a Class Member (as defined in the Class Notice), and that the information in this Claim Form and any documentation attached to it are true and correct to the best of my knowledge. If I did not provide required documents, it is because I do not have them.

    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@BenefitRecoverySettlement.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
    First Name
    Middle Initial
    Last Name
    Street Address
    City
    State
    Zip Code
    Email Address
    Phone Number
    Signature
    Date

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

    Click here to edit your Claim.