ATTENTION: This Claim Form is to be used to apply for relief related to the Data Breach that potentially affected individuals who were customers of insurance brokers that were, in turn, customers of Insurance Technologies Corp. and Zywave, Inc. in February 2021. There are three types of damages for which these individuals may be eligible: 1) statutory damages for Settlement Class Members who were California residents at the time of the Data Breach and whose Social Security number and/or driver’s license information were accessed or potentially accessed in the Data Breach, 2) for all Settlement Class Members, reimbursement of actual losses that are reasonably traceable to the Data Breach, including attested time, and 3) for all Settlement Class Members, 12 months of Financial Shield, an identity theft protection service provided by Aura, and 12 months of identity restoration services, also provided by Aura.
To submit a Claim, you must have been identified as a potential Settlement Class Member from Defendants Insurance Technologies Corp. and Zywave, Inc.’s business records and received Notice of this Settlement with a unique Claim Number. If you apply for statutory damages, you may qualify for a payment of up to $300 (the “Statutory Claim”).
You may also apply to be reimbursed for your actual out-of-pocket losses, up to $5,000.00, and for time spent remedying identity theft or fraud, including misuse of personal information, credit monitoring or freezing credit reports at twenty-five dollars ($25.00) for up to 8 hours (the “Out-of-Pocket Loss Claim”). You will need to submit proof of your losses in order to be eligible. PLEASE BE ADVISED that any documentation you provide must be submitted WITH this Claim Form.
Note that you MUST separately apply for statutory damages and out-of-pocket losses, including attested time using this claim form.
CLAIM VERIFICATION: All Claims are subject to verification. You will be notified if additional information is needed to verify your Claim.
ASSISTANCE: If you have questions about this Claim Form, please visit the Settlement website at [INSERT] for additional information or call 1-855-944-3456.
PLEASE KEEP A COPY OF YOUR CLAIM FORM AND PROOF OF MAILING FOR YOUR RECORDS.
Failure to submit required documentation, or to complete all parts of the Claim Form, may result in denial of the claim, delay its processing, or otherwise adversely affect the claim.
Section A. Confirm Your Eligibility
Did you receive a unique Claim Number indicating that you may be a member of the Settlement Class?
If yes, continue to the next question. If no, you are not a member of the Settlement Class and do not qualify to file a Claim.
Did you suffer any financial expenses or other financial losses that you believe was as a result of the Data Breach? For example, did you sign up and pay for a credit monitoring service, hire and pay for a professional service to remedy identity theft, etc. as a direct result of or attributed to the Data Breach?
If yes, you may be eligible to fill out Section C of this form and provide corroborating documentation. If no, you may not be eligible to submit a claim for “out-of-pocket” losses but may still be eligible to fill out Section B of this form for a Statutory Claim.
Section B. California Statutory Claims
Settlement Class Members who were California residents at the time of the Data Breach may be eligible to seek payment as relief for the Statutory Claim aspect of the settlement, subject to verification of certain information.
To verify eligibility, you must provide your full name, mailing address, email address, and phone number, which will be validated against the mailing address in Defendants’ records at the time of the Data Breach. Only Settlement Class Members who resided in California at the time of the Data Breach and whose Social Security number or driver’s license information were accessed or potentially accessed in the Data Breach may submit a Statutory Claim. If it is verified that you meet all the criteria described in the Settlement Agreement and the mailing address you provide above matches the mailing address in Defendants’ business records, you will be eligible to receive a payment of up to $300. The information you provide must match what was in Defendant’s business records at the time of the Data Breach. If it does not, the Settlement Administrator will deny your claim, unless it determines in its discretion that the mailing address you provide above is sufficiently similar to the mailing address in Defendants’ business records at the time of the Data Breach.
If the total dollar amount of Claims for losses exceeds the limits set by the Settlement Agreement, your Statutory Claim payment may be reduced, depending on the number of valid Claims received.
Payment for your Statutory Claim will be paid directly to you electronically. If you do not wish to receive an electronic payment, you can request to receive payment by check and sent to the mailing address you provided above.
Section C. Reimbursement for Documented Losses
If you suffered verifiable financial losses that are reasonably traceable to the Data Breach, you may be eligible to receive a payment to compensate you for the losses and inconveniences suffered that are fairly traceable to the Data Breach.
If it is verified that you meet all the criteria described in the Settlement Agreement, and you submit proof of your losses and the dollar amount of those losses, you will be eligible to receive a payment compensating you for your documented losses of up to $5,000.00. Examples of what can be used to prove your losses include: receipts, account statements, etc. You may also prove losses by submitting information in the claim form that describes time spent remedying suspected identity theft, fraud, or misuse of personal information and/or other issues reasonably traceable to the Data Breach. You will be required to provide an attestation and a brief description of (1) the action taken in response to the Data Breach; and (2) the time associated with each action. If you submit this information, you will be eligible for a payment of up to $25.00 per hour, for up to 8 hours. Examples of what can be used to prove your losses related to time spent remedying issues fairly traceable to the Data Breach include: time spent monitoring credit, resolving disputes for unauthorized transactions, freezing or unfreezing your credit, remedying a falsified tax return, etc.
Providing adequate proof of your losses does not guaranty that you will be entitled to receive the full amount claimed. All Claims will also be subject to an aggregate maximum payment amount, as explained in the Settlement Agreement. If the amount of losses claimed exceeds the maximum amount of money available under the Settlement Agreement, then the payment for your Claim will be reduced on a pro rata basis. If you would like to learn more, please review the Settlement Agreement for further details.
Payment for your losses will be paid directly to you electronically, unless you request to be paid by check as indicated below.
For each loss that you believe can be traced to the Data Breach, please provide a description of the loss, the date of the loss, the dollar amount of the loss, and the type of documentation you will be submitting to support the loss.
Examples of such losses include payments for identity theft protection or credit monitoring you made which are reasonably traceable to the Data Breach, financial losses due to stolen identity traceable to the Data Breach, etc. These are only examples and do not represent a complete list of losses eligible for compensation. Please provide a description of any loss that you claim was the result of the Data Breach.
Examples of documentation include receipts for identity theft protection services, etc. + Add Loss
Reimbursement for Attested Time:
Settlement Class Members may submit a claim for up to 8 hours of time spent remedying identity theft, fraud, misuse of personal information, credit monitoring or freezing credit reports, and/or other issues reasonably traceable to the Data Breach at $25.00 per hour by providing an attestation and a brief description of (1) the action taken in response to the Data Breach; and (2) the time associated with each action.
+ Add Time
If you believe that there is additional information related to your losses that would be helpful for the evaluation of your Claim, please explain:
By checking the below box, I hereby declare under penalty of perjury under the laws of the State of Texas that the information provided in this Claim Form to support my seeking relief for Attested Time (up to $200.00) is true and correct. I further certify that any documentation that I have submitted in support of my Claim for Attested Time consists of unaltered documents in my possession.
Yes, I understand that I am submitting this Claim Form and the affirmations it makes as to my seeking relief for Attested Time under penalty of perjury. I further understand that my failure to check this box may render my Claim for Attested Time null and void.