Online Claim Form

Deadline to Submit Claim Form: March 21, 2022

CLAIM FORM FOR INMEDIATA SECURITY INCIDENT
SETTLEMENT BENEFITS

Inmediata Data Security Litigation, Case No. 3:19-cv-01811

USE THIS FORM TO MAKE A CLAIM FOR CREDIT MONITORING AND INSURANCE SERVICES; CASH PAYMENTS FOR REIMBURSEMENT OF OUT-OF-POCKET LOSSES OR THE DEFAULT SETTLEMENT PAYMENT, AND CALIFORNIA SETTLEMENT PAYMENT

The DEADLINE to submit this Claim Form is: March 21, 2022

I. GENERAL INSTRUCTIONS

If you were notified that your private information (“Personal Information”) could have been accessed in the Security Incident wherein Inmediata’s computer network system was the target of an external criminal-cyberattack that began in January 2019, you are a “Class Member.” If you received a notice about this class action Settlement addressed to you, then the Settlement Administrator has already determined that you are a Class Member.

As a Class Member, you are eligible to receive two years of free Credit Monitoring and Identity Theft Insurance Services (“Credit Monitoring & Insurance Services”), up to a $2,500 cash payment for reimbursement of costs or expenditures actually incurred and that are plausibly traceable to the Security Incident (“Out-of-Pocket Losses”), and a cash payment of up to $50 if you were a California resident as of January 1, 2019 and you received a notice from Inmediata that your information could have been accessed in the Security Incident, as compensation under the California Confidentiality of Medical Information Act (“California Settlement Payment”).

The free Credit Monitoring & Insurance Services will be the Web Watcher plan provided by Kroll’s, valued at $47 per year. If you already subscribed to the Web Watcher plan with Kroll’s, one additional year will be added to your current plan for free. If you already have a similar service from another provider, you can request that this service start after your other service expires.

To claim the Credit Monitoring & Insurance Services, you need only provide your email address and the unique claim number provided to you in the notice that you received by e-mail.

Cash payments amounts may be reduced pro rata (proportionately) depending on how many people submit such claims. Additional payments may also be sent. Complete information about the Settlement and its benefits are available at www.inmediatadatabreachsettlement.com.

This Claim Form may be submitted electronically via the Settlement Website at www.inmediatadatabreachsettlement.com or completed and mailed to the address below. Please type or legibly print all requested information, in blue or black ink. Mail your completed Claim Form, including any supporting documentation, by U.S. mail to:

Inmediata Security Incident Settlement
c/o ILYM Group, Inc.
P.O. Box 2031
Tustin, CA 92781 

II. CLAIMANT INFORMATION

The Settlement Administrator will use this information for all communications regarding this Claim Form and the Settlement. If this information changes prior to distribution of cash payments and Credit Monitoring & Insurance Services, you must notify the Settlement Administrator in writing at the address above.

First Name

Middle Initial

Last Name

Mailing Address, Line 1: Street Address/P.O. Box

Mailing Address, Line 2:

City

State

Select a State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip Code

Telephone Number (Home)

Telephone Number (Other)

Email Address (for Credit Monitoring & Insurance Services)

Date of Birth (mm/dd/yyyy)

Unique ID Provided on mailed Notice (if known)

You will receive your payment by check in the mail.

III. CREDIT MONITORING & INSURANCE SERVICES

If you wish to receive Credit Monitoring & Insurance Services, please provide your email address in the space provided in Section II, above, and return this Claim Form. Submitting this Claim Form will not automatically enroll you into Credit Monitoring & Insurance Services. To enroll, you must follow the instructions sent to your email address, above, after the Settlement is approved and becomes final (the “Effective Date”).

IV. REIMBURSEMENT FOR OUT-OF-POCKET LOSSES

In addition to Credit Monitoring & Insurance Services, you may also seek reimbursement for up to $2,500 of Out-of-Pocket Losses you incurred that are plausibly traceable to the Security Incident. Out-of-Pocket Losses include, for example: late fees, declined payment fees, overdraft fees, returned check fees, customer service fees, card cancellation or replacement fees, credit-related costs related to purchasing credit reports, credit monitoring or identity theft protection, costs to place a freeze or alert on credit reports, costs to replace a driver’s license, state identification card, or social security number, which are attributable to the Security Incident.

In order to make a claim for Out-of-Pocket Losses you must (i) fill out the information below and/or on a separate sheet submitted with this Claim Form; (ii) sign the attestation at the end of this Claim Form (section VI); and (iii) include Reasonable Documentation supporting each claimed cost along with this Claim Form. Out-of-Pocket Losses will be deemed plausibly traceable to the Security Incident by the Settlement Administrator if the Out-of-Pocket Losses occurred on or after January 1, 2019 through the date of your claim submission, and the Settlement Administrator determines that the Out-of-Pocket Losses were incurred as a result of the Security Incident.

Cost Type (Fill all that apply)

Unreimbursed fraud losses or charges Professional fees incurred in connection with identity theft or falsified tax returns Lost interest or other damages resulting from a delayed state and/or federal tax refund in connection with fraudulent tax return filing Credit freeze Credit monitoring that was ordered after January 1, 2019 through the date on which the Credit Monitoring & Insurance Services become available through this Settlement Other (provided detailed description) Time Expenditures: Hours for time spent taking actions intended to remedy fraud, identity theft, or other misuse of Personal Information

V. CALIFORNIA SETTLEMENT PAYMENT

In addition to Credit Monitoring & Insurance Services and reimbursement of Out-of-Pocket Losses or the Default Settlement Payment, you may file a claim for the California Settlement Payment of up to $50 if, as of January 1, 2019, you were a California resident, and you received a notice from Inmediata that your information could have been accessed in the Security Incident.

If you qualify and wish to receive the California Settlement Payment, simply check the box below, and return this Claim Form.

Yes, I would like to receive the California Settlement Payment.

VI. ATTESTATION
(REQUIRED FOR CLAIMS FOR OUT-OF-POCKET LOSSES)

I, , declare that I expended the Out-of-Pocket Losses claimed above.

I declare under penalty of perjury under the laws of and of the United States of America that the foregoing is true and correct. Executed on , in .

X Click to sign

By:

Date: January 21st 2022