Submit Claim | Health Aid Settlement

The deadline for submitting this form is August 22, 2022

General Claim Form Information

This Claim Form should be filled out if your private information was maintained on Health Aid of Ohio’s computer systems and/or network that was compromised in the Data Incident on or about February 19, 2021.

Provide Your Contact Information

First Name *

Last Name *

Street Address *

City *

State *

Zip Code *

Email Address *

Phone Number *

* Required Fields

Credit Monitoring and Identity Restoration Services

Members of the Settlement Class are eligible for credit monitoring and identity restoration services and are defined as: All persons whose Private Information was maintained on Defendant Health Aid's system and who were sent a Notice of Data Breach as a result of the Data Incident.

Initials

By initialing here, I certify I am a Member of the Settlement Class and I request the free one-year of credit monitoring and identity restoration services provided by ID Experts (IDX), which includes $1,000,000 in identity theft insurance. Please note, if you are a member of the Settlement Class and pre-registered for credit monitoring and identity restoration services, you do not need to submit a claim form to activate these services.

Monetary Compensation

This part of the Claim Form applies only to Class Members whose Social Security Numbers were included in the database on which notice was based. You would know if you were one of these individuals because you would have received complimentary credit monitoring in the Notice of the Data Incident. If you are NOT a member of this Subclass or if you are a member of this Subclass, but have no monetary Claims, move ahead to the Claimant Information page.

Initials

By initialing here, I also certify that I am also a member of the Social Security Number (“SSN”) Subclass of the Settlement Class defined as: All members of the Settlement Class whose Social Security numbers were included in the database on which notice was based and who were offered complimentary credit monitoring in the notice of the Data Incident.

Amount

As a member of this subclass, I am submitting a claim for monetary losses in the amount of $ on account of out-of-pocket expenses, Extraordinary Losses, and/or time spent addressing the Data Incident. I understand that I am required to provide supporting third-party documentation and, if claiming Extraordinary Losses pursuant to Section 4.2 of the Settlement Agreement, a statement verifying this claim is true and correct to the best of my knowledge and belief and is made under penalty of perjury.

More detailed information about Monetary Claims for the SSN Subclass can be found in Section 4.2 of the Settlement Agreement.

Purchase Receipts

Out of Pocket Expenses

Please provide copies of any receipts, bank statements, reports, or other documentation supporting your claim. This can include receipts or other documentation not “self-prepared” by you. “Self-prepared” documents such as handwritten receipts are, by themselves, insufficient to receive reimbursement, but can be considered to add clarity or support other submitted documentation. The settlement administrator may contact you for additional information before processing your claim.

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

Extraordinary Losses

Please provide the documentation necessary to support any Claim for Extraordinary Losses as defined in Section 4.2 of the Settlement Agreement. For example, copies of any receipts, bank statements, reports, or other documentation supporting your claim. This can include receipts or other documentation not “self-prepared” by you. “Self-prepared” documents such as handwritten receipts are, by themselves, insufficient to receive reimbursement, but can be considered to add clarity or support other submitted documentation. The settlement administrator may contact you for additional information before processing your claim.

You may mark out any information that is not relevant to your claim before sending in the 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.

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Lost Time

Members of the SSN subclass may submit a Claim for Lost Time at a rate of $15/hour if at least one hour of time was spent remedying fraud, identity theft, or other alleged misuse of personal information traceable to the Data Incident or spent on preventative and remedial measures to protect personal information that are traceable to the Data Incident.

Please provide an attestation setting forth the amount of time (up to four hours) spent dealing with the Data Incident and an explanation of how the time was spent on preventative, remedial or other measures related to the Data Incident.

Signature

Signature *

Date

KATHLEEN DEVINE, ET AL V. HEALTH AID OF OHIO, INC.

CASE No. CV-21-948117

IN THE COURT OF COMMON PLEAS CUYAHOGA COUNTY, OHIO

The deadline for submitting this form is August 22, 2022

General Claim Form Information

Credit Monitoring and Identity Restoration Services

Monetary Compensation

Your Claim Form has been submitted successfully.

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
City
State
Zip Code
Email Address
Phone Number