If you received a personalized notice in the mail or via email with a Notice ID and Confirmation Code, please enter the codes you were provided below.

Please remember to enter the full Notice ID exactly as it appears on your personalized Notice, (i.e. 12345678).

If you believe you are a Settlement Class Member, and you did not receive a personalized notice in the mail with a Notice ID and Confirmation Code, please contact the Settlement Administrator and we will provide one to you.

The deadline for submitting this proof of claim form is

This claim form should be filled out online or submitted by mail if your personal information was allegedly compromised as a result of the data incident that UMass Memorial Health Care, Inc. discovered on or about January 27, 2021 (the “Data Incident”), and you would like to receive a benefit from the settlement. You may receive a payment or other benefit if you fill out this claim form, if the settlement is approved, and if you are found to be eligible for a payment.

The settlement notice describes your legal rights and options. Please visit the official settlement administration website, www.UMMHCClassSettlement.com or call 1-844-696-1314 for more information.

If you wish to submit a claim for a settlement payment, you need to provide the information requested below. Please print clearly in blue or black ink. This claim form must be mailed and postmarked by April 14, 2023.

I. CLASS MEMBER NAME AND CONTACT INFORMATION

Provide your name and contact information below. You must notify the Settlement Administrator if your contact information changes after you submit this form.

* Required Fields

II. RELIEF SELECTION

Please select the relief you would like from either Section 2.A or Section 2.B below.

Please review the notice and section VI of the Settlement Agreement (available at www.UMMHCClassSettlement.com) for more information on who is eligible for a payment and the nature of the expenses or losses that can be claimed.

If you do not clearly indicate whether you would prefer option 2.A or 2.B below, your claim form may be deemed invalid.

By marking this line, I willingly forego all compensation under Section 2.B. of this Claim Form and instead opt for a flat cash payment of approximately $40, subject to proration depending on how many claims are made.

Please provide as much information as you can to help us figure out if you are entitled to a settlement payment.

PLEASE PROVIDE THE INFORMATION LISTED BELOW:

Check the box for each category of benefits you would like to claim. Categories include: reimbursement for ordinary losses (up to a maximum of $150.00), reimbursement for lost time (up to 3 hours at $25 per hour), reimbursement of extraordinary losses incurred as a result of the Data Incident (up to a maximum of $5,000), and 24-months of identity theft monitoring to be paid for by Defendant. Please be sure to fill in the total amount you are claiming for each category and to attach documentation of the charges as described in bold type (if you are asked to provide account statements as part of proof required for any part of your claim, you may mark out any unrelated transactions if you wish).

Ordinary Out-of-Pocket Expenses Resulting from the Data Incident

Examples - documented bank fees, long distance phone charges, cell phone charges (only if charged by the minute), data charges (only if charged based on the amount of data used), postage, gasoline for local travel, and bank fees. This category also includes fees for credit reports, credit monitoring, or other identity theft insurance product purchased between June 24, 2020, and April 14, 2023.

All ordinary out-of-pocket expenses must be more likely than not attributable to the Data Incident.

$

Documentation of out-of-pocket expenses is required

If you are seeking reimbursement for fees, expenses, or charges, you MUST attach a copy of a statement from the company that charged you, or a receipt for the amount you incurred.

If you are seeking reimbursement for credit reports, credit monitoring, or other identity theft insurance product purchased between June 24, 2020, and April 14, 2023, you MUST attach a copy of a receipt or other proof of purchase for each credit report or product purchased.
(Note: By claiming reimbursement in this category, you certify that you purchased the credit monitoring or identity theft insurance product primarily because of the Data Incident and not for any other purpose).

Supporting documentation must be provided. You may mark out any transactions that are not relevant to your claim before sending in the documentation.

Extraordinary Expenses Resulting from the Data Incident
$

Documentation of the extraordinary loss is required. The loss MUST be actual, documented, and unreimbursed monetary loss that occurred between June 24, 2020, and April 14, 2023. Additionally, the loss MUST be more likely than not the result of the Data Incident and MUST not already be covered by the ordinary reimbursement category.

You may mark out any transactions that are not relevant to your claim before sending in the documentation.

Between one and three hours of documented time spent dealing with the Data Incident

Examples – You spent at least one-half hour calling customer service lines, writing letters or emails, or on the Internet in order to get fraudulent charges reversed or in updating automatic payment programs because your card number changed. You spent at least one-half hour rescheduling medical appointments and/or finding alternative medical care and treatment, retaking or submitting to medical tests, locating medical records, retracing medical history as a result of the Data Incident.

Hours (up to 3 hours):
Claim up to 24-months of credit monitoring and identity protection services.

The Settlement requires Defendant to provide up to 24-months of credit monitoring and identity protection services.

III. Supporting 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.

File List: No Files Selected

    IV. Payment Method

    You have successfully requested a payment. Click here if you would like to choose a different payment method.

    V. SIGN AND DATE YOUR CLAIM FORM

    I declare under penalty of perjury under the laws of the United States and the laws of my State of residence that the information supplied in this claim form by the undersigned is true and correct to the best of my recollection, and that this form was executed on the date set forth below.

    I understand that I may be asked to provide supplemental information by the Settlement Administrator before my claim will be considered complete and valid.

    MAIL YOUR CLAIM FORM OR SUBMIT YOUR CLAIM FORM ONLINE.

    This claim form must be:

    Postmarked by April 14, 2023 and mailed to: P.O. Box 58220, Philadelphia, PA 19102, c/o UMMHC Settlement Administrator; OR

    Submitted through the Settlement Website by midnight on April 14, 2023 at: www.UMMHCClassSettlement.com.

    Your Claim Form has been submitted successfully.

    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
    Last Name
    Street Address
    Street Address 2
    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@UMMHCClassSettlement.com

    Click here to edit your Claim.

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