McNicholas v. Illinois Gastroenterology Group, P.L.L.C.

Provide your name and contact information below. You must notify the Settlement Administrator if your contact information changes after you submit this form.

Eligibility: Settlement Class Member whose Social Security Numbers were compromised in the Data Breach, Settlement Class Members whose PBI information was compromised in the Data Breach, and Settlement California Subclass Members with CMIA claims against IGG whose PHI was compromised in the Data Breach.

Note: You can only select one (1) of the Alternative Cash Payment options. Alternative Cash Payments cannot be combined with Documented Ordinary Losses, Documented Extraordinary Losses, or Credit Monitoring benefits.

Eligibility: Settlement Class Members whose Social Security Numbers were not compromised in the Data Breach, but whose PHI was compromised in the Data Breach.

Note: You can only select one (1) of the Alternative Cash Payment options. Alternative Cash Payments cannot be combined with Documented Ordinary Losses, Documented Extraordinary Losses or Credit Monitoring benefits.

Settlement Class Members are eligible for compensation for unreimbursed ordinary losses up to a total of $200.00 per Settlement Class Member, upon submission of a valid Claim Form and supporting documentation (except for claims for lost time).

Ordinary losses may include: (a) out-of-pocket expenses incurred as a result of the Data Breach, such as the following: (i) bank fees, (ii) long distance phone charges, (iii) cell phone charges (only if charged by the minute), (iv) data charges (only if charged based on the amount of data used), (v) postage, and (vi) gasoline for local travel; (b) fees for credit reports, credit monitoring, or other identity theft insurance product purchased between October 22, 2021 and June 16, 2023; and (c) up to three (3) hours of lost time, calculated at $25/hour, for time spent responding to issues raised by the Data Breach.

Please note that the above list of reimbursable documented ordinary losses is not meant to be exhaustive, but is exemplary. You may make claims for any documented losses that you believe are reasonably related to the Data Breach or to mitigating the effects of the Data Breach.

Supporting documentation must be provided. You may mark out any transactions that are not relevant to your claim before sending in the documentation.

Compensation for Lost Time

Settlement Class Members are eligible for compensation for extraordinary losses resulting from the Data Breach, including proven actual monetary losses, upon submission of a valid Claim Form and supporting documentation, up to $5,000 per Settlement Class Member, provided that: (i) the loss is an actual, documented, and unreimbursed monetary loss; (ii) the loss was more likely than not caused by the Data Breach; (iii) the loss occurred between October 22, 2021 and June 16, 2023; (iv) the loss is not already covered by one or more of the normal reimbursement categories; (v) you made reasonable efforts to avoid the loss or seek reimbursement for the loss, including, but not limited to, exhaustion of all available credit monitoring insurance and identity theft insurance.

Documentation of the extraordinary loss(es) is required. The loss(es) must be more likely than not the result of the Data Breach and must not already be covered by the ordinary losses reimbursement.

Settlement Class Members are eligible for compensation for extraordinary losses resulting from the Data Breach, including proven actual monetary losses, upon submission of a valid Claim Form and supporting documentation, up to $5,000 per Settlement Class Member, provided that: (i) the loss is an actual, documented, and unreimbursed monetary loss; (ii) the loss was more likely than not caused by the Data Breach; (iii) the loss occurred between October 22, 2021 and June 16, 2023; (iv) the loss is not already covered by one or more of the normal reimbursement categories; (v) you made reasonable efforts to avoid the loss or seek reimbursement for the loss, including, but not limited to, exhaustion of all available credit monitoring insurance and identity theft insurance.

Settling Class Members whose claim forms are determined to be timely and valid will receive their cash payments via an electronic payment method or by check. Please ensure you provide a current, valid email address in Section I of this claim form. If the email address you include with your submission becomes invalid for any reason, it is your responsibility to provide accurate contact information to the Settlement Administrator to receive a payment.

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I affirm 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 that all information provided on this Claim Form is subject to verification and that I may be asked to provide supplemental information by the Settlement Administrator before my claim will be considered complete and valid.