Step 1 of 10 10% Unique IDThis field is hidden when viewing the formhidden last name* Celeste Brown and Ross Finesmith. v. AllCare Plus Pharmacy LLC Suffolk County Superior Court Commonwealth of Massachusetts Complete this Claim Form if you are a Settlement Class Member and you wish to receive Settlement benefits. UNDER THIS SETTLEMENT YOU MAY BE ENTITLED TO A PAYMENT OF AT LEAST $50 You are a member of the Settlement Class and eligible to submit a Claim Form if: You are an individual who resides in the in the United States whose Protected Information was subjected to compromise in the Data Security Incident affecting AllCare Plus Pharmacy LLC on or around June 21, 2022. Excluded from the Settlement Class are (i) AllCare Plus Pharmacy LLC, its officers and directors; (ii) all Settlement Class Members who timely and validly request exclusion from the Settlement Class; (iii) any judges assigned to this case and their staff and family; and (iv) any other person found by a court of competent jurisdiction to be guilty under criminal law of initiating, causing, aiding or abetting the criminal activity occurrence of the Security Incident or who pleads nolo contendere to any such charge.Settlement Class Members may be eligible to receive benefits including a payment of $50 or free credit reporting provided by IDX and other relief. Settlement Class Members can submit a Claim Form for: (1) Two years of credit monitoring at no charge; (2) Ordinary Loss Expense Reimbursement of up to a total of $750 per claimant; (3) Lost Time Reimbursement of $20 per hour for up to 5 hours (for a total of $100, subject to the $750 cap on Ordinary Loss claims and/or the $5,000 cap on Extraordinary Loss claims); and (4) Extraordinary Losses Reimbursement of up to $5,000 per claimant. In the alternative to making a claim for (1) – (4) above, Settlement Class Members may elect to receive an Alternative Cash Payment of $50. Ordinary Losses: Settlement Class Members may submit a claim for up to $750.00 in Ordinary Losses. Ordinary Losses must be supported with documentation and include, without limitation, and by way of example, unreimbursed losses relating to fraud or identity theft; professional fees including attorneys’ fees, accountants’ fees, and fees for credit repair services; credit monitoring costs; and miscellaneous expenses such as fax, postage, copying, and mileage that were incurred on or after June 21, 2022. Extraordinary Losses: Settlement Class Members are also eligible to receive reimbursement for documented extraordinary losses, not to exceed $5,000 per Settlement Class Member, including proven actual monetary losses, provided that: (i) the loss is an actual, documented, and unreimbursed monetary loss; (ii) the loss was more likely than not caused by the Data Security Incident; and (iii) the loss was incurred after June 21, 2022. Lost Time:Settlement Class Members may submit a claim for up to $20 per hour for up to five (5) hours for time actually spent responding to issues raised by the Data Security Incident. This is subject to the Ordinary and Extraordinary Losses caps, as applicable. To receive reimbursement for Lost Time, the claimant must include an attestation affirming the time spent and a written description of how the time was spent. This payment shall be included in the per person cap for compensation for Ordinary and Extraordinary Losses, as applicable. Please note, the five (5) hours total for Lost Time may not be submitted twice – i.e., for a claim of Ordinary Losses and a separate claim of Extraordinary Losses. Credit Monitoring Services. All Settlement Class Members, except those who opt to receive the $50 Alternative Cash Payment, shall be offered an opportunity to enroll in two years of free credit monitoring provided through IDX, including at least $1,000,000 in identity theft protection insurance. Alternative Cash Payment Claims In the alternative to claims for Ordinary Losses, Lost Time, Extraordinary Losses, and/or Credit Monitoring (i.e., all of the reimbursement categories defined above), Settlement Class Members can elect a $50.00 Alternative Cash Payment. I. SETTLEMENT CLASS MEMBER NAME AND CONTACT INFORMATIONProvide your name and contact information below. You must notify the Settlement Administrator if your contact information changes after you submit this Claim Form. Name* First Last Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Zip Code Email Address* Telephone Number*Claimant ID Number* II. ORDINARY LOSSESOrdinary Losses checkbox Check this box if you are requesting compensation for Ordinary Losses up to a total of $750. You must submit supporting documentation demonstrating actual Ordinary Losses. Complete the fields below describing the supporting documentation you are submitting.ordinary losses table*Description of Ordinary Loss Documentation ProvidedAmount Add RemoveSupporting Documents for ORDINARY Losses* Drop files here or Select files Accepted file types: pdf, jpg, jpeg, bmp, png, docx, doc, xlsx, xls, Max. file size: 24 MB, Max. files: 10. III. EXTRAORDINARY LOSSESEXTRAORDINARY LOSSES checkbox Check this box if you are requesting compensation for Unreimbursed Extraordinary Losses up to a total of $5,000. You must submit supporting documentation demonstrating actual, unreimbursed monetary loss. Complete the fields below describing the supporting documentation you are submitting.extraordinary losses table*Description of Extraordinary Loss Documentation ProvidedAmount Add RemoveSupporting Documents for EXTRAORDINARY Losses* Drop files here or Select files Accepted file types: pdf, jpg, jpeg, bmp, png, docx, doc, xlsx, xls, Max. file size: 24 MB, Max. files: 10. IV. LOST TIMECheck for lost time Check this box if you spent time responding to issues raised by the Data Security Incident. You can submit a claim for reimbursement of $20 per hour up to 5 hours (for a total of $100, subject to the $750 for Ordinary Losses or $5,000 cap for Unreimbursed Extraordinary Losses). By checking this box, you are attesting that the activities you performed were related to the Security Incident.Indicate the number of hours spent**** Select an Answer ***1 Hour2 Hours3 Hours4 Hours5 HoursDescription of How Lost Time was Spent* V. CREDIT MONITORING SERVICEScredit monitoring Check this box if you wish to enroll in Credit Monitoring Services at no cost to you for two years, which includes credit monitoring through IDX and $1,000,000 in identity theft protection insurance. VI. ALTERNATIVE CASH PAYMENTalternate payment checkbox 2 Check this box if you wish to receive an Alternative Cash Payment of $50. You cannot receive this payment if you make a claim for any of the benefits previously mentioned in Sections II – V (Ordinary Loss, Extraordinary Loss, Lost Time, or Credit Monitoring). Claim Benefits SummaryBelow is a summary of the claims you have elected on this Claim Form. Please verify before proceeding. If you did not elect any claim benefits, please go back and select your claim benefit before proceeding.* ORDINARY LOSSES* EXTRAORDINARY LOSSES * LOST TIME * CREDIT MONITORING * ALTERNATIVE CASH PAYMENTNo claims selected* You have not selected any claim benefits. Please go back and select at least one claim benefit to proceed. VII. PAYMENT SELECTIONPlease select one of the following payment options, which will be used should you be eligible to receive a Settlement payment: Chosen Payment Method*This field is hidden when viewing the formPayment Token* VIII. ATTESTATION & SIGNATURESignature* I swear and affirm that the information provided in this Claim Form, and any supporting documentation provided is true and correct to the best of my knowledge. I understand that my claim is subject to verification and that I may be asked to provide supplemental information by the Claims Administrator before my claim is considered complete and valid.
