Sign the Claim Form and submit it to the Settlement Administrator Sample Clauses

Sign the Claim Form and submit it to the Settlement Administrator. After you complete this Claim Form, sign it below and submit it by United States Mail to the Settlement Administrator, postmarked no later than (81 days after preliminary approval order is entered), at the following address: Xxxxxxx x. Xxxxxx Settlement Administrator P.O. Box ##### #####-#### I certify that the statements herein are true to the best of my knowledge, and that I am not submitting multiple claim forms in this settlement, except as disclosed herein. Signature: Dated: / / Print Name: EXHIBIT 0 XXXXXX XXXXXX XXXXXXXX XXXXX XXXXXXX XXXXXXXX XX XXXXXXXXX XXXXXXX XXXXXXX, on behalf of himself and others similarly situated, Plaintiff, v. SAGENT AUTO, LLC d/b/a SAGENT LENDING TECHNOLOGIES.1 Defendant. Case No. 2:18-cv-1054 [PROPOSED]
Sample 1
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Sign the Claim Form and submit it to the Settlement Administrator. After you complete this Claim Form, sign it below and submit it by United States Mail to the Settlement Administrator, postmarked no later than , 2019, at the following address: Xxxxxx x. ICOT Hearing Systems, LLC d/b/a ListenClear Settlement Administrator P.O. Box ##### Louisville, KY #####-#### NOTE: Only one claim is permitted per telephone number: I certify that the statements herein are true and correct to the best of my knowledge, and that I am not submitting multiple claim forms in this settlement, except as disclosed herein. Signature: Dated: / / Print Name: 35655987v1 EXHIBIT 5 IN THE UNITED STATES DISTRICT COURT FOR THE NORTHERN DISTRICT OF GEORGIA ATLANTA DIVISION XXXXXXX XXXXXX, on behalf of ) himself and others similarly situated, ) ) Plaintiff, ) Case No. 1:18-CV-02045-WMR ) v. ) ) ICOT HEARING SYSTEMS, LLC, ) D/B/A LISTENCLEAR and ICOT ) HOLDINGS, LLC, ) et al. ) ) Defendants, ) ) ) [PROPOSED]
Sample 1

Related to Sign the Claim Form and submit it to the Settlement Administrator

  • Settlement Administrator 52. The Settlement Administrator shall administer various aspects of the Settlement as described in the next Paragraph and perform such other functions as are specified for the Settlement Administrator elsewhere in this Agreement, including, but not limited to, providing Mail Notice to Settlement Class Members as described in Section VII; effecting Publication Notice; establishing and operating the Settlement Website and a toll-free number; administering the Claims processes; and distributing cash payments according to the processes and criteria set forth in Section X and Exhibits 5, 6, and 7.

  • Appointment of Settlement Administrator After obtaining a quote from mutually acceptable and qualified settlement administrators, the Parties have mutually agreed to ask the Court to appoint Simpluris as the qualified administrator, to serve as the Settlement Administrator, which, as a condition of appointment, will agree to be bound by this Agreement with respect to the performance of its duties and its compensation. The Settlement Administrator’s duties will include preparing, printing, and mailing the Class Notice Packet to all Class Members; conducting a National Change of Address search to update Class Member addresses before mailing the Class Notice Packets; re-mailing Class Notice Packets that are returned to the Class Member’s new address; setting up a toll-free telephone number to receive calls from Class Members; receiving and reviewing for validity completed Elections Not to Participate in Settlement; providing the Parties with weekly status reports about the delivery of Class Notice Packets and receipt of completed Elections Not to Participate in Settlement; calculating Settlement Shares; issuing the checks to effectuate the payments due under the Settlement; issuing the tax reports required under this Settlement; and otherwise administering the Settlement pursuant to this Agreement. The Settlement Administrator will have the authority to resolve all disputes concerning the calculation of a Participating Class Member’s Settlement Share, subject to the dollar limitations and calculations set forth in this Agreement. The Settlement Administration Expenses, including the cost of printing and mailing the Class Notice Packet, will be paid out of the Gross Settlement Amount. The Settlement Administrator shall have its own Employer Identification Number under Internal Revenue Service Form W-9 and shall use its own Employer Identification Number in calculating payroll withholdings for taxes and shall transmit the required employers’ and employees’ share of the withholdings to the appropriate state and federal tax authorities. The Settlement Administrator shall establish a settlement fund that meets the requirements of a Qualified Settlement Fund (“QSF”) under US Treasury Regulation section 468B-1.

  • CLAIM PROCEDURES Claim forms or claim information as to the subject policy can be obtained by contacting Benmark, Inc. (800-544-6079). When the Named Fiduciary has a claim which may be covered under the provisions described in the insurance policy, they should contact the office named above, and they will either complete a claim form and forward it to an authorized representative of the Insurer or advise the named Fiduciary what further requirements are necessary. The Insurer will evaluate and make a decision as to payment. If the claim is payable, a benefit check will be issued in accordance with the terms of this Agreement. In the event that a claim is not eligible under the policy, the Insurer will notify the Named Fiduciary of the denial pursuant to the requirements under the terms of the policy. If the Named Fiduciary is dissatisfied with the denial of the claim and wishes to contest such claim denial, they should contact the office named above and they will assist in making an inquiry to the Insurer. All objections to the Insurer's actions should be in writing and submitted to the office named above for transmittal to the Insurer.

  • Selection of Representatives a) Each central party and the Crown shall select its own representatives to the Committee.

  • Claims Administrator A. The Human Resources Director through his/her designated Claims Administrators shall administer the provision of this policy. The City Physician shall provide the City's Claims Administrators with all available medical information concerning the Employee's injury and/or medical opinions as requested. Medical information and opinions shall be based upon the Employee's medical records and/or physical examination. Questions of Employee eligibility shall be determined by the provisions established under State Statute 49-110, 49-111 and Oklahoma Worker's Compensation Title 85. Prior to any denial of injury leave benefits where lost time actually occurred, the administrator shall notify Union and allow a Union representative the opportunity to review the application pending denial and provide any additional information relating to same as may be necessary. Should the City change designated Claims Administrators Local 176 will be notified in writing.

  • Claims Submission We will submit your claims and assist you in any way we reasonably can to help get your claims paid. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request. Please be aware that the balance of your claim is your responsibility whether or not your insurance company pays your claim. Your insurance benefit is a contract between you and your insurance company; we are not party to that contract.

  • Dispute Settlement Procedures (1) If a dispute relates to:

  • Claim Procedure Any Person entitled to indemnification hereunder shall (i) give prompt written notice to the indemnifying party of any claim with respect to which it seeks indemnification (provided that the failure to give prompt notice shall impair any Person’s right to indemnification hereunder only to the extent such failure has prejudiced the indemnifying party) and (ii) unless in such indemnified party’s reasonable judgment a conflict of interest between such indemnified and indemnifying parties may exist with respect to such claim, permit such indemnifying party to assume the defense of such claim with counsel reasonably satisfactory to the indemnified party. If such defense is assumed, the indemnifying party shall not be subject to any liability for any settlement made by the indemnified party without its consent (but such consent shall not be unreasonably withheld, conditioned or delayed). An indemnifying party who is not entitled to, or elects not to, assume the defense of a claim shall not be obligated to pay the fees and expenses of more than one counsel for all parties indemnified by such indemnifying party with respect to such claim, unless in the reasonable judgment of any indemnified party a conflict of interest may exist between such indemnified party and any other of such indemnified parties with respect to such claim. In such instance, the conflicted indemnified parties shall have a right to retain one separate counsel, chosen by the Holders representing a majority of the Registrable Securities included in the registration if such Holders are indemnified parties, at the expense of the indemnifying party.

  • Required Confidentiality Claim Form This is a requirement of the TIPS Contract and is non-negotiable. TIPS provides the required TIPS Confidentiality Claim Form in the "Attachments" section of this solicitation. Vendor must execute this form by either signing and waiving any confidentiality claim, or designating portions of Vendor's proposal confidential. If Vendor considers any portion of Vendor's proposal to be confidential and not subject to public disclosure pursuant to Chapter 552 Texas Gov’t Code or other law(s) and orders, Vendor must have identified the claimed confidential materials through proper execution of the Confidentiality Claim Form. If TIPS receives a public information act or similar request, any responsive documentation not deemed confidential by you in this manner will be automatically released. For Vendor documents deemed confidential by you in this manner, TIPS will follow procedures of controlling statute(s) regarding any claim of confidentiality and shall not be liable for any release of information required by law, including Attorney General determination and opinion. Notwithstanding any other Vendor designation of Vendor's proposal as confidential or proprietary, Vendor’s submission of this proposal constitutes Vendor’s agreement that proper execution of the required TIPS Confidentiality Claim Form is the only way to assert any portion of Vendor's proposal as confidential.

  • Claims Procedures Each Party entitled to be indemnified by the other Party (an “Indemnified Party”) pursuant to Section 8.1 or 8.2 hereof shall give notice to the other Party (an “Indemnifying Party”) promptly after such Indemnified Party has actual knowledge of any threatened or asserted claim as to which indemnity may be sought, and shall permit the Indemnifying Party to assume the defense of any such claim or any litigation resulting therefrom; provided:

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