Acrisure Claim Form Step 1 of 7 14% ClaimFormNo 17th Judicial Cir., Kent County, Mich.Dias Jr. et al. v. Acrisure, LLCCase No Case No. 24-02304-NZ Your claim must be submitted online byNOVEMBER 14, 2024 GENERAL INSTRUCTIONS Complete this Claim Form if you are a Settlement Class Member and you wish to receive Settlement benefits. You are a member of the Settlement Class and eligible to submit a Claim Form if: You are an individual who resides in the United States if your Personal Information was impacted by the data security incident that affected Acrisure in or around December 2022 (“Security Incident”).Excluded from the Settlement Class are (i) Acrisure, its officers and directors; (ii) all Settlement Class Members who timely and validly request exclusion from the Settlement Class; (iii) any judges assigned to this case and their staff and family; and (iv) any other person found by a court of competent jurisdiction to be guilty under criminal law of initiating, causing, aiding or abetting the criminal activity occurrence of the Security Incident or who pleads nolo contendere to any such charge.Settlement Class Members may submit a Claim Form for: (1) 2 years of credit monitoring; (2) Unreimbursed Loss Claims – up to a total of $4,000 per claimant; and (3) Lost Time – $25 per hour for up to 4 hours (for a total of $100, subject to the $4,000 cap on Unreimbursed Loss Claims).Credit Monitoring Services. All Settlement Class Members shall have the ability to make a claim for 2 years of one-credit bureau credit monitoring services and identity protection services by choosing this benefit on the Claim Form. Even if Settlement Class Members previously accepted the Defendant’s offer of complimentary credit monitoring services, they may still claim this benefit. Unreimbursed Losses up to a total of $4,000 per claimant, upon submission of a valid claim with supporting documentation, if: i. The loss is an actual, documented, and unreimbursed monetary loss; ii. The loss was more likely than not caused by the Security Incident; and iii. The loss occurred between December 1, 2022 and the end of the Claims Period. Unreimbursed losses include, without limitation, and by way of example, unreimbursed losses relating to fraud or identity theft; professional fees including attorneys’ fees, accountants’ fees, and fees for credit repair services; costs associated with freezing or unfreezing credit with any credit reporting agency; credit monitoring costs that were incurred on or after mailing of the notice of data security incident, through the date of claim submission; and miscellaneous expenses such as notary, fax, postage, copying, mileage, and long-distance telephone charges.Lost Time Claims for reimbursement of $25 per hour up to 4 hours (for a total of $100) with an attestation on the Claim Form that the activities performed were related to the Security Incident. Claims for Lost Time are subject to the $4,000 cap for Unreimbursed Losses (discussed above).This Claim Form may be submitted electronically via the Settlement Website at www.acrisuredatasecuritysettlement.com or completed and mailed, including any supporting documentation, to: Acrisure Security Incident Administrator, PO Box 64053, Saint Paul, MN 55164. SETTLEMENT CLASS MEMBER NAME AND CONTACT INFORMATIONProvide your name and contact information below. You must notify the Settlement Administrator if your contact information changes after you submit this Claim Form. Notice ID* Name* First Last Mailing Address* Street Address Address Line 2 City State / Province / Region Zip Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country HiddenCheck if address is non-US Please check if this is a non-U.S. address Current Email Address* Current Phone Number* UNREIMBURSED LOSSES AND LOST TIME SELECTIONCheckbox unreimbursed losses Check this box if you are requesting compensation for Unreimbursed Losses up to a total of $4,000.00. *You must submit supporting documentation demonstrating actual, unreimbursed monetary loss. Complete the chart below describing the supporting documentation you are submitting. Section 3 Time Spent TableDescription of Documentation ProvidedAmount Supporting Documents for 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, Max. files: 9. You must provide documentation for each claimed out-of-pocket expense listed above.Checkbox lost time Check this box if you spent time monitoring accounts or otherwise dealing with issues related to the Security Incident. You can submit a claim for reimbursement of $25 per hour up to 4 hours (for a total of $100, subject to the $4,000.00 cap for Unreimbursed Losses). By checking the box above, you are attesting the activities you performed were related to the Security Incident. Indicate the number of hours spent:*** Select Hours Spent ***1 Hour2 Hours3 Hours4 Hours CREDIT MONITORING SERVICESCheckbox credit monitoring Check this box if you wish to enroll in one-bureau credit monitoring services for 2 years, which includes, among other things, $1,000,000 in identity theft insurance. For those selecting credit monitoring, a “code” will be sent to you by email that you will use to enroll. Please be sure to enter an email address, above, or we will not be able to provide the code. Below is a summary of the claims you have elected on this Claim Form. Please verify before proceeding. If you did not elect any claim benefits, please go back and select your claim benefit before proceeding.* Unreimbursed losses* Unreimbursed lost time * Credit MonitoringNo claims selected* You have not selected any claim benefits. Please go back and select at least one claim benefit to proceed. PAYMENT SELECTIONPlease select one of the following payment options, which will be used should you be eligible to receive a Settlement payment: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. Payment Method* HiddenPayment Token Since you elected Credit Monitoring only as a benefit, you do not need to complete this section. Click ‘Next’ to continue. ATTESTATION & SIGNATURE* I swear and affirm under the laws of the United States 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. I understand my claim is subject to verification and that I may be asked to provide supplemental information by the Settlement Administrator before my claim is considered complete and valid. 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