Abubaker v. Dominion Dental USA, Inc. et al.

Case Number 1:19-cv-01050-LMB-MSN

United States District Court, Eastern District of Virginia

If you received a personalized notice in the mail or via email with a Notice ID and Confirmation Code, please enter the codes you were provided below.

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

CLAIM FORM FOR DOMINION DENTAL SECURITY INCIDENT SETTLEMENT BENEFITS

USE THIS FORM TO MAKE A CLAIM FOR PAYMENTS FOR REIMBURSEMENT OF OUT-OF-POCKET LOSSES, LOST TIME and/or EXTRAORDINARY LOSSES

Please click the link for GENERAL INSTRUCTIONS

I. GENERAL INSTRUCTIONS

If you were notified that your private information (“Personal Information”) could have been accessed in the Security Incident wherein Dominion Dental’s computer network system was the target of an external criminal-cyberattack that began as early as August 25, 2010, you are a “Class Member.” If you received a notice about this class action Settlement addressed to you, then the Settlement Administrator has already determined that you are a Class Member.

As a Class Member, you may be eligible to receive up to $300 total for ordinary unreimbursed losses, including up to $100 in compensation for lost time incurred as a result of the Security Incident (“Out-of-Pocket Losses”), and up to $7,500 cash payment for reimbursement of extraordinary, proven monetary losses that are reasonably and fairly traceable to the Security Incident (“Extraordinary Losses”).

If you intend to make a claim for Out-of-Pocket Losses or Extraordinary Losses, you will need to submit supporting documentation.

Please read the claim form carefully and answer all questions. Failure to provide required information could result in a denial of your claim.

II. CLAIMANT INFORMATION
* Required Fields

You will receive your payment by check in the mail, unless you prefer payment via PayPal, or Venmo. If so, please select which you prefer and provide the phone number or email address associated with your account.

III. REIMBURSEMENT FOR OUT-OF-POCKET LOSSES

You may seek reimbursement for up to $300 in Out-of-Pocket Losses you incurred as a result of the Security Incident. Out-of-Pocket Losses include, for example: late fees, declined payment fees, overdraft fees, returned check fees, customer service fees, card cancellation or replacement fees, credit-related costs related to purchasing credit reports, credit monitoring or identity theft protection, costs to place a freeze or alert on credit reports, costs to replace a driver’s license, state identification card, or social security number, which are attributable to the Security Incident.

As part of your claim for Out-of-Pocket losses, you may also make a claim for up to five (5) hours of lost time, compensated at $20/hr. for a total of up to $100, for time spent dealing with the Security Incident.

Cost Type
(Fill all that apply)		 Approximate Date of Loss Amount of Loss

Examples: Account statement with unauthorized charges highlighted; Correspondence from financial institution declining to reimburse you for fraudulent charges

Examples: Receipt for hiring service to assist you in addressing identity theft; Accountant bill for re-filing tax return

Examples: Letter from IRS or state about tax fraud in your name; Documents reflecting length of time you waited to receive your tax refund and the amount

Examples: Notices or account statements reflecting payment for a credit freeze

Example: Receipts or account statements reflecting purchases made for Credit Monitoring & Insurance Services

Example: Phone bills, gas receipts, postage receipts; detailed list of locations to which you traveled (i.e. police station, IRS office), indication of why you traveled there (i.e. police report or letter from IRS re: falsified tax return) and number of miles you traveled

Please provide detailed description below or in a separate document submitted with this Claim Form

Please provide a detailed explanation of the time spent dealing with the Security Incident, including approximate number of hours spent for each separate task. You are not required to, but may, submit supporting documentation.
IV. EXTRAORDINARY LOSSES

You may also seek reimbursement for up to $7,500 for proven Extraordinary Losses only if (i) the loss is an actual, documented, and unreimbursed (except from your insurer) monetary loss; (ii) fairly traceable to the Security Incident; (iii) the loss occurred between August 25, 2010 and the Claims Deadline; and (iv) the loss is not already covered by one or more of the normal reimbursement categories above (including the Out-of-Pocket Losses set forth above) and (v) the loss exceeds all available credit monitoring insurance and identity theft insurance previously provided to you by Dominion National. Please provide an itemized list of any Extraordinary Losses below, if you need additional lines, you may attach additional pages containing this information with your claim:

Cost Type Approximate Date of Loss Amount of Loss
V. SUPPORTING DOCUMENTATION

If you are having trouble uploading your supporting documentation, you may send to the Settlement Administrator at info@DominionDentalSettlement.com. Please include your Notice ID and Confirmation Code in the email.

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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    VI. ATTESTATION

    I, , declare that I expended the Out-of-Pocket and/or Extraordinary Losses claims above. I declare under penalty of perjury under the laws of and of the United State of America that the foregoing is true and correct. Executed on , in , .

    Your Claim Form 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@DominionDentalSettlement.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
    M.I.
    Last Name
    Mailing Address, Line 1
    Mailing Address, Line 2
    City
    State
    Zip Code
    Telephone Number (Home)
    Telephone Number (Other)
    Email Address
    Signature
    Date

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

    Click here to edit your Claim.