CLAIMANT INFORMATION. The Claims Administrator will use this information for all communications regarding this Claim Form. If this information changes, you MUST notify the Claims Administrator in writing at the address above. Complete names of all persons and entities must be provided. Beneficial Owner’s Name First Name Last Name Joint Beneficial Owner’s Name (if applicable) First Name Last Name If this claim is submitted for an XXX, and if you would like any check that you MAY be eligible to receive made payable to the XXX, please include “XXX” in the “Last Name” box above (e.g., Xxxxx XXX). Entity Name (if the Beneficial Owner is not an individual) Name of Representative, if applicable (executor, administrator, trustee, c/o, etc.), if different from Beneficial Owner Last 4 digits of Social Security Number or Taxpayer Identification Number Street Address City State/Province Zip Code Foreign Postal Code (if applicable) Foreign Country (if applicable) Telephone Number (Day) Telephone Number (Evening) Email Address (email address is not required, but if you provide it you authorize the Claims Administrator to use it in providing you with information relevant to this claim) Type of Beneficial Owner: Specify one of the following: Individual(s) Corporation UGMA Custodian XXX Partnership Estate Trust Other (describe: )
CLAIMANT INFORMATION. The Claims Administrator will use this information for all communications regarding this Claim Form. If this information changes, you MUST notify the Claims Administrator in writing at the address above. Claimant Names(s) (as the name(s) should appear on check, if eligible for payment; if the shares are jointly owned, the names of all beneficial owners must be provided): Name of Person the Claims Administrator Should Contact Regarding this Claim Form (Must Be Provided): Mailing Address – Line 1: Street Address/P.O. Box: Mailing Address – Line 2 (If Applicable): Apartment/Suite/Floor Number: City: State/Province: Zip Code: Country: Last 4 digits of Claimant Social Security/Taxpayer Identification Number:1
CLAIMANT INFORMATION. You must provide your name and current contact information below. It is your responsibility to tell the Settlement Administrator if your contact information changes after you submit this form. FIRST NAME LAST NAME STREET ADDRESS CITY STATE ZIP CODE TELEPHONE NUMBER EMAIL ADDRESS
CLAIMANT INFORMATION. The amount of any individual payment or Award made to an Enrolled Claimant under this Agreement (such amount information, “Award Information”), shall be kept confidential by Bayer, the Claims Administrator and the QSF Administrator and shall not be disclosed except (i) to appropriate Persons to the extent necessary to process Program Claims or provide benefits under this Agreement, (ii) as otherwise expressly provided in this Agreement, (iii) as may be required by law, lawful compulsory order or listing agreements, (iv) as may be reasonably necessary in order to enforce, or exercise Bayer’s rights under, or with respect to, such Enrolled Claimant’s Claims Form(s), Release(s), Stipulation(s) of Dismissal or (with respect to such Enrolled Claimant or his Counsel, as applicable) this Agreement or (v) in any action brought by Bayer for contribution against any Additional Released Party, provided that such Award Information shall be protected by the highest level of confidentiality available under the protective order in such case. All Enrolled Claimants shall be deemed to have consented to the disclosure of the Award Information for these purposes.
CLAIMANT INFORMATION. The Claims Administrator will use this information for all communications regarding this claim (including the check, if eligible for payment). If this information changes, you MUST notify the Claims Administrator in writing at the address above. Claimant Name(s): Street Address: City: State: Zip Code: Country: Last four digits of Social Security Number or Taxpayer Identification Number:
CLAIMANT INFORMATION. The Claims Administrator will use this information for all communications regarding this Claim Form. If this information changes, you MUST notify the Claims Administrator in writing at the address above. Complete names of all persons and entities must be provided. Beneficial Owner’s First Name MI Beneficial Owner’s Last Name Co-Beneficial Owner’s First Name MI Co-Beneficial Owner’s Last Name Entity Name (if claimant is not an individual) Address1 (street name and number) City State ZIP/Postal Code Telephone Number (home) Telephone Number (work) Email address □ Individual (includes joint owner accounts) □ Pension Plan □ Trust □ Corporation □ Estate □ IRA/401K □ Other (please specify)
CLAIMANT INFORMATION. FIRST NAME MIDDLE NAME LAST NAME ADDRESS 1 ADDRESS 2 - CITY STATE ZIP (optional)
CLAIMANT INFORMATION. The information you provide below will be used only to contact you regarding the Settlement and process your claim. If your contact information changes after you submit your Claim, please notify us promptly by emailing the Settlement Administrator at . First Name: Middle Name: Last Name: Street Address: City: State: Zip: Primary Phone Number: Primary Email Address: (Your email address will only be used to communicate with you regarding the Settlement.)
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 approved reimbursements, you must notify the Settlement Administrator in writing at the address above. First Name M.I. Last Name Mailing Address, Line 1: Street Address/P.O. Box Mailing Address, Line 2: City: State: Zip Code: - - - - Telephone Numbers (Home) Telephone Numbers (Other) Email Address Unique ID Provided on mailed Notice (if known) You will receive your payment by check in the mail, unless you prefer payment via PayPal, or Venmo. If so, please select which you prefer and provide the phone number or email address associated with your account. PayPal □ Venmo □
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 and Insurance Services, you must notify the Settlement Administrator in writing at the address above. First Name M.I. Last Name Alternative Name(s) Mailing Address, Line 1: Street Address/P.O. Box Mailing Address, Line 2: City: State: Zip Code: - - - - Telephone Numbers (Home) Telephone Numbers (Home) Email Address Date of Birth (mm/dd/yyyy) Claim Number Provided on mailed Notice (if known) / / You may only select one of the following options:
