CLAIM FORM FOR OUT-OF-POCKET COSTS

USE THIS FORM TO MAKE A CLAIM FOR REIMBURSEMENT OF OUT-OF-POCKET COSTS YOU BELIEVE YOU INCURRED AS A RESULT OF THE ANTHEM DATA BREACH

YOU MAY MAKE A CLAIM FOR OUT-OF-POCKET COSTS IN ADDITION TO A CLAIM FOR CREDIT MONITORING SERVICES OR ALTERNATIVE COMPENSATION

You may also file a claim for Credit Monitoring Services or Alternative Compensation here

GENERAL INSTRUCTIONS

Settlement Class Members are entitled to request reimbursement of “Out-of-Pocket Costs” that they believe they incurred as a result of the Anthem Data Breach. If you received a notice from Anthem about the Data Breach announced in February 2015 or if your personal information was taken during the Data Breach, you are a “Settlement Class Member.” If you received a mailed postcard notice from the Settlement Administrator about this class action settlement addressed to you, then you are a Settlement Class Member. If you have your Claim Number and would like to file a claim click here.

If you are a Settlement Class Member, and you believe you spent money or lost time or money related to the Data Breach, then you may make a documented claim for reimbursement. The Settlement reserves a fund of $15 million to pay all valid Out-of-Pocket Costs Claims of all Settlement Class Members, and each individual claim may not exceed $10,000. Such claims received on or before the Effective Date will be processed together. The earliest possible Effective Date is March 5, 2018. If the total amount of approved claims received on or before the Effective Date exceeds $15 million, then the amount of each claim will be reduced proportionally (by a percentage) until the total payments for Out-of-Pocket Costs Claims is equal to $15 million.

After the Effective Date, if $15 million has not already been claimed for Out-of-Pocket Costs, claims will be processed in the order they are received, on a first-come first-served basis, until one year after the Final Approval Date. The Final Approval Date is estimated to be on or around February 1, 2018. Once the $15 million fund is exhausted, no more claims for Out-Of-Pocket Costs will be paid.

Out-of-Pocket Costs incurred after January 2015 which may be eligible for reimbursement include:

This list provides examples only, and other costs due to the Data Breach may also be eligible for reimbursement. YOU MUST BE ABLE TO DOCUMENT YOUR CLAIM. Original documents will not be returned; submit copies only.

The Settlement Administrator has the sole authority to determine the validity of claims for Out-Of-Pocket Costs. Only valid claims will be paid. The deadline to file an Out-of-Pocket Costs Claim will be one year after the Settlement is finally approved.

If you are a Settlement Class Member, you may also claim two years of Credit Monitoring Services at no cost to you, or Alternative Compensation if you already have credit monitoring and certify that you will keep it until at least October 30, 2018, by filing a Credit Monitoring Services or Alternative Compensation Claim Form, available here.

In order for your claim to be considered, you must fully complete this Claim Form. Type all information, answering all questions below. Please submit the completed Claim Form, including any documentation that may be required, to the Settlement Administrator as soon as possible, but no later than one year after Final Approval.


CLAIMANT INFORMATION

*Please Note – If you submit a valid claim form, payment will be sent to the Name provided above.



DOCUMENTATION OF HARM
$

CLAIMS FOR ADDITIONAL TIME

If, in addition to the above, if you spent time remedying issues related to the Data Breach, you may be compensated at $15 per hour or unpaid time off work at your actual hourly rate, whichever is greater. You will not be compensated for more than 10 hours of time spent remedying issues related to the Data Breach without a detailed showing how this time was expended and why it was necessary.

If you spent time remedying issues relating to the Anthem Data Breach, please indicate the number of hours here:

If you took unpaid time off work, please provide documentation of the number of hours that you took off work, and provide your hourly wage below.

Please explain in detail how this time was expended and why it was necessary:

Please also provide documentation of the potential fraud and / or identity theft that made this expenditure of time necessary (i.e.letter from IRS or bank; police report).

Upload Your Documentation

Maximum file size: 10 mb

Allowed file types: .pdf, .jpg, .jpeg, .tif, .tiff, .gif, .png

Uploaded Files

Check this box if you would prefer to mail in documentation. You will be allowed to print a transmittal letter after submitting this form, to include with your mailed-in documentation.


Payment Option
I would like to receive payment by:
             

Email Address to receive payment by PayPal (update if different from above)

PayPal Payment Reminder: If your Email address changes, you need to let the Claims Administrator know of your new Email address.

Check Payment Reminder: If your mailing address changes, you need to let the Claims Administrator know of your new address.

CERTIFICATION

Check this box if filing on behalf of the Claimant

Note: Evidence of authority to act on behalf of Claimant may be required

Please explain capacity:

Required