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. 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 or legibly print all information in blue or black ink, answering all questions below. Please submit the completed Claim Form, including any documentation that may be required, to the Settlement Administrator by U.S. mail as soon as possible, but no later than one year after Final Approval, at the following address:

In re Anthem, Inc. Data Breach Litigation
P.O. Box 404012
Louisville, KY 40233-9821


CLAIMANT INFORMATION

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




Check this box if filing on behalf of the Claimant

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

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