Heath, et al. v. Insurance Technologies Corp. and Zywave, Inc.

Case No. 3:21-cv-01444-N

United States District Court for the Northern District of Texas

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Please remember to enter the full Notice ID exactly as it appears on your personalized Notice, (i.e. 12345678).

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ATTENTION: This Claim Form is to be used to apply for relief related to the Data Breach that potentially affected individuals who were customers of insurance brokers that were, in turn, customers of Insurance Technologies Corp. and Zywave, Inc. in February 2021. There are three types of damages for which these individuals may be eligible: 1) statutory damages for Settlement Class Members who were California residents at the time of the Data Breach and whose Social Security number and/or driver’s license information were accessed or potentially accessed in the Data Breach, 2) for all Settlement Class Members, reimbursement of actual losses that are reasonably traceable to the Data Breach, including attested time, and 3) for all Settlement Class Members, 12 months of Financial Shield, an identity theft protection service provided by Aura, and 12 months of identity restoration services, also provided by Aura.

To submit a Claim, you must have been identified as a potential Settlement Class Member from Defendants Insurance Technologies Corp. and Zywave, Inc.’s business records and received Notice of this Settlement with a unique Claim Number. If you apply for statutory damages, you may qualify for a payment of up to $300 (the “Statutory Claim”).

You may also apply to be reimbursed for your actual out-of-pocket losses, up to $5,000.00, and for time spent remedying identity theft or fraud, including misuse of personal information, credit monitoring or freezing credit reports at twenty-five dollars ($25.00) for up to 8 hours (the “Out-of-Pocket Loss Claim”). You will need to submit proof of your losses in order to be eligible. PLEASE BE ADVISED that any documentation you provide must be submitted WITH this Claim Form.

Note that you MUST separately apply for statutory damages and out-of-pocket losses, including attested time using this claim form.

CLAIM VERIFICATION: All Claims are subject to verification. You will be notified if additional information is needed to verify your Claim.

ASSISTANCE: If you have questions about this Claim Form, please visit the Settlement website at [INSERT] for additional information or call 1-855-944-3456.

PLEASE KEEP A COPY OF YOUR CLAIM FORM AND PROOF OF MAILING FOR YOUR RECORDS.

Failure to submit required documentation, or to complete all parts of the Claim Form, may result in denial of the claim, delay its processing, or otherwise adversely affect the claim.

REGISTRATION
* Required Fields

We received your Settlement Claim in the Heath et al v Insurance Technologies Corp. and Zywave, Inc. class action settlement. Your claim has been determined to be deficient in part for the following reason(s):

Instructions. Please follow the instructions below and answer the questions as instructed.

CLAIM INFORMATION

Section A. Reimbursement for Documented Losses

If you suffered verifiable financial losses that are reasonably traceable to the Data Breach, you may be eligible to receive a payment to compensate you for the losses and inconveniences suffered that are fairly traceable to the Data Breach.

If it is verified that you meet all the criteria described in the Settlement Agreement, and you submit proof of your losses and the dollar amount of those losses, you will be eligible to receive a payment compensating you for your documented losses of up to $5,000.00. Examples of what can be used to prove your losses include: receipts, account statements, etc. You may also prove losses by submitting information in the claim form that describes time spent remedying suspected identity theft, fraud, or misuse of personal information and/or other issues reasonably traceable to the Data Breach. You will be required to provide an attestation and a brief description of (1) the action taken in response to the Data Breach; and (2) the time associated with each action. If you submit this information, you will be eligible for a payment of up to $25.00 per hour, for up to 8 hours. Examples of what can be used to prove your losses related to time spent remedying issues fairly traceable to the Data Breach include: time spent monitoring credit, resolving disputes for unauthorized transactions, freezing or unfreezing your credit, remedying a falsified tax return, etc.

Providing adequate proof of your losses does not guaranty that you will be entitled to receive the full amount claimed. All Claims will also be subject to an aggregate maximum payment amount, as explained in the Settlement Agreement. If the amount of losses claimed exceeds the maximum amount of money available under the Settlement Agreement, then the payment for your Claim will be reduced on a pro rata basis. If you would like to learn more, please review the Settlement Agreement for further details.

Payment for your losses will be paid directly to you electronically, unless you request to be paid by check as indicated below.

For each loss that you believe can be traced to the Data Breach, please provide a description of the loss, the date of the loss, the dollar amount of the loss, and the type of documentation you will be submitting to support the loss. You must provide ALL this information for this Claim to be processed. Supporting documents must be submitted electronically. Please do so as part of this Claim Form and provide the additional information required below. If you fail to provide sufficient supporting documents, the Settlement Administrator will deny Your Claim. Please provide only copies of your supporting documents and keep all originals for your personal files. The Settlement Administrator will have no obligation to return any supporting documentation to you. A copy of the Settlement Administrator’s privacy policy is available on this website. With the exception of your Insurance Technologies Corp. and/or Zywave, Inc. name, mailing address, email address, and phone number, supporting documentation will not be provided to Defendants in this action. Please do not directly communicate with Insurance Technologies Corp. and/or Zywave, Inc. regarding this matter. All inquiries are to be sent to the Claims Administrator.

Examples of such losses include payments for identity theft protection or credit monitoring you made which are reasonably traceable to the Data Breach, financial losses due to stolen identity traceable to the Data Breach, etc. These are only examples and do not represent a complete list of losses eligible for compensation. Please provide a description of any loss that you claim was the result of the Data Breach.

Examples of documentation include receipts for identity theft protection services, etc.

Description of the Loss Date of Loss Amount Type of Supporting Documentation
Example:
Identity Theft Protection Service		 07/17/2020 $50.00 Copy of identity theft protection service bill
Example:
Fees paid to a professional to remedy a falsified tax return		 02/30/2021 $25.00 Copy of the professional services bill

Description of the Loss 1

Date of Loss 1

Amount 1

Type of Supporting Documentation 1
+ Add Loss

Reimbursement for Attested Time:

Settlement Class Members may submit a claim for up to 8 hours of time spent remedying identity theft, fraud, misuse of personal information, credit monitoring or freezing credit reports, and/or other issues reasonably traceable to the Data Breach at $25.00 per hour by providing an attestation and a brief description of (1) the action taken in response to the Data Breach; and (2) the time associated with each action.

Date of Attested Time Amount of Time Description of the Action Taken
07/17/2020 1 Hour Example: Review my credit report
07/20/2020 1.5 Hours Example: Call with bank to dispute transaction.

Date of Attested Time 1

Amount of Time 1

Description of the Action Taken 1
+ Add Time

Additional Information

By checking the below box, I hereby declare under penalty of perjury under the laws of the State of Texas that the information provided in this Claim Form to support my seeking relief for Attested Time (up to $200.00) is true and correct. I further certify that any documentation that I have submitted in support of my Claim for Attested Time consists of unaltered documents in my possession.

Section B. Payment

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Section C. Supporting 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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    Section D. Settlement Class Member Affirmation

    By submitting this Claim Form and checking the box below, I declare that I received notification from Insurance Technologies Corp. and/or Zywave, Inc. that I have been identified as a potential Settlement Class Member. As I have submitted claims of losses due to the Data Breach, I declare that I suffered these losses.

    I understand that my Claim and the information provided above will be subject to verification.

    I also understand that I may not be entitled to recover under this Settlement if I am employed by and/or affiliated with the Judge or Magistrate presiding over this action, and/or am employed by the Defendants or anyone acting on their behalf.

    By submitting this Claim Form, I certify that any documentation that I have submitted in support of my Claim consists of unaltered documents in my possession.

    Your Deficiency Response has been submitted successfully.

    HOWEVER, it appears one or more of the documents you uploaded were not successfully received. Please see below for which file(s) had errors and log back in to your existing Claim online to re-upload your document(s). Alternatively, you can send your documents with your Submitted Claim ID to the Settlement Administrator by email to: info@ITCSettlement.com.

    Please print this page for your records.

    Your Claim Details

    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
    MI
    Last Name
    Mailing Address
    City
    State
    Zip Code
    Email Address
    Telephone Number
    Signature
    Date

    If you have any questions regarding your Claim, please provide the Submitted Claim ID listed above and email us at info@ITCSettlement.com