Step 1 of 10 10% This field is hidden when viewing the formhidden claimant id*This field is hidden when viewing the formhidden last name* CLAIM FORM Beer v Bluefield University Case No. 1:23-cv-00055-MFU-PMS If you are a resident of the United States and were sent a notice letter from Bluefield University (“Bluefield,” or “Defendant”) notifying you that your Private Information was compromised in a Data Breach Incident (the “Incident”) on May 1, 2023, use this form to make a claim for Documented Out-Of-Pocket Losses, and/or reimbursement of Lost Time, and/or Identity Theft Protection and Credit Monitoring Services, or a one-time Alternative Cash Payment. GENERAL INSTRUCTIONS. If you fit the above description and are a member of the Settlement Class you are eligible to complete this Claim Form to request reimbursement for Documented Out-Of-Pocket Losses as a result of the Incident up to a maximum of $4,500 per Person, compensation for up to 5 hours of Lost Time at $25 per hour for time spent reasonably related to mitigating the effects of the Incident (with any payment for Lost Time counting towards the $4,500 cap), and/or three (3) years of one-bureau Identity Theft Protection and Credit Monitoring Services. If you previously opted to receive the complimentary credit monitoring services offered by Bluefield following the May 1, 2023 incident, you are still eligible to enroll in the three (3) years of Identity Theft Protection and Credit Monitoring Services provided by this Settlement. -OR- In lieu of receiving reimbursement for Documented Out-Of-Pocket expenses, reimbursement for Lost Time, and/or Identity Theft Protection and Credit Monitoring Services as described above, you may elect to submit a claim for a one-time Alternative Cash Payment of up to $100. You cannot receive any of the benefits described in the prior paragraph, including three (3) years of Identity Theft Protection and Credit Monitoring Services, if you elect to receive the Alternative Cash Payment.Please read the Claim Form carefully and answer all questions. Failure to provide the required information could result in a denial of your claim. This Claim Form can be completed and submitted with the required documentation or mailed to the address below. Claim Forms must be submitted on or before April 7, 2025. Please legibly print all requested information, in blue or black ink. Mail your completed Claim Form, including any supporting documentation, by U.S. mail to the address below. Documentation provided in support of your claim will not be returned, please retain copies of your documents for your personal records. Bluefield University Data Breach Settlement c/o Atticus Administration PO Box 64053 St. Paul, MN 55164 I. CLASS MEMBER NAME AND CONTACT INFORMATIONProvide your name and contact information below. You must notify the Claims Administrator if your contact information changes after you submit this form. NAME:* First Name Last Name Mailing Address* Mailing 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 This field is hidden when viewing the formCheck if address is non-US Please check if this is a non-U.S. address Email Address* Telephone Number* II. PROOF OF CLASS MEMBERSHIPI certify that I reside in the United States and received notice from Bluefield that my Private Information was compromised in a data breach incident on May 1, 2023 YES NO Enter the seven-digit Notice ID Number printed above your name and address on your mailed Notice or the last four digits of your Social Security Number:This field is hidden when viewing the formclaimant id*Claimant ID Number*Social Security Number (last four digits) III. IDENTITY THEFT PROTECTION AND CREDIT MONITORING SERVICESI wish to receive three (3) years of Identity Theft Protection and Credit Monitoring Services. I wish to receive three (3) years of Identity Theft Protection and Credit Monitoring Services. IV. DOCUMENTED OUT-OF-POCKET LOSSESComplete this section of the Claim Form to be reimbursed for Documented Out-Of-Pocket Losses that you incurred as a result of the Incident, up to a maximum of $4,500. Documentation to substantiate your claim(s) is required and must accompany your Claim Form. Ordinary Out-of-Pocket Checkbox Check this box if you are seeking reimbursement for documented out-of-pocket Losses. Documented Ordinary Losses Table*Documented Out-of-Pocket Loss DescriptionDateDollar AmountSupport Documentation Description Supporting Documents for Documented Out-of-Pocket Losses* Drop files here or Select files Accepted file types: pdf, jpg, jpeg, bmp, png, docx, doc, xlsx, xls, Max. file size: 16 MB. To qualify for Out-Of-Pocket Loss Reimbursements, documentation must be provided for each claimed Out-Of-Pocket Loss listed above. V. LOST TIMEComplete this section of the Claim Form to receive compensation for up to five (5) hours of Lost Time at $25 per hour for time spent reasonably related to mitigating the effects of the Incident, up to $4,500 including reimbursement for Documented Out-Of-Pocket Losses.Check this box if are seeking reimbursement for time spent dealing with the Data Incident and indicate how many hours of lost time you spent: Check this box if you are seeking reimbursement time spent dealing with the Data Incident and indicate how many hours of lost time you spent: I am claiming Lost Time in the total hours (rounding up to the next hour) indicated below:**** Select an Answer ***1 Hour ($25)2 Hours ($50)3 Hours ($75)4 Hours ($100)5 Hours ($125)Lost Time Attest Checkbox* I attest and affirm to the best of my knowledge and belief that any claimed Lost Time was spent reasonably related to mitigating the effects of the Incident. VI. ALTERNATIVE CASH PAYMENTComplete this section of the Claim Form to receive a cash payment of $100.00 in lieu of other benefits offered. The below attestation is required to be eligible Alternative Cash Payment. in lieu of Identity Theft Protection, Out-of-Pocket Losses & Lost Time I am claiming the Alternative Cash Payment in lieu of Identity Theft Protection, Out-of-Pocket Losses & Lost Time Benefit Selection Summary Please review your selected benefits below. You may go back and make any changes, or continue onto the payment selection portion of the claim form. * Theft Protection and Credit Monitoring Services*OUT-OF-POCKET LOSSES*LOST TIME*ALTERNATIVE CASH PAYMENTNo benefit radio button You have not selected any claim benefits. Please go back and select at least one claim benefit to proceed. VII. PAYMENT SELECTIONPlease select one payment method for receipt of any Settlement payment to which you are determined eligible Payment Method*This field is hidden when viewing the formPayment Token* YOU WILL RECEIVE A VERIFICATION EMAIL REGARDING YOUR DIGITAL PAYMENT. YOU MUST VERIFY AND AUTHENTICATE YOUR PAYMENT INFORMATION IN ORDER TO RECEIVE A DIGITAL PAYMENT. IF YOU DO NOT VERIFY AND AUTHENTICATE YOUR INFORMATION, A PAPER CHECK WILL BE SENT TO YOU. VIII. ATTESTATION & SIGNATURESignature checkbox* I swear and affirm under the laws of my state that the information I have supplied in this Claim Form is true and correct to the best of my recollection, and that this form was executed on the date set forth below. Printed Signature*Date* MM slash DD slash YYYY PLEASE MAKE SURE YOUR CLAIM FORM IS COMPLETE, SIGNED, AND INCLUDES DOCUMENTATION TO SUPPORT ANY OUT-OF-POCKET LOSSES BEING CLAIMED. THE CLAIM FORM MUST BE POSTMARKED FOR MAIL OR SUBMITTED ONLINE ON OR BEFORE APRIL 7, 2025. 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