Alexander v. Salud Family Health - Submit a Claim Page 1

Unique ID:

Please provide the Unique ID provide in the Notice that you received.*

The Claims Administrator will use this information for all communications regarding this Claim Form and the Settlement. If this information changes prior to distribution of cash payments and Credit Monitoring and Insurance Services, you must notify the Claims Administrator in writing at the address found on the Contact page here.

First Name:*

Middle Initial:

Last Name:*

Alternate Name(s):

Date of Birth:*

Please indicate if you are a parent or guardian submitting this claim on behalf of a minor*

Yes. I am a parent or guardian submitting this claim on behalf of a minor.
No

Parent/Guardian Information:

First Name:*

Middle Initial:

Last Name:*

By checking this box, I attest that I am the parent or guardian of the Claimant named in this Claim Form.*

Country:*

Address Line 1:*

Address Line 2:

Address Line 3:

Address Line 4:

Address Line 5:

City:*

State:*

Province:*

ZIP Code:*

Postal Code:*

Phone Number:

Email Address:*

Please Note: The email address provided above will be used for all communication regarding your claim.

Alexander v. Salud Family Health, Inc.

Submit a Claim - Page 1

Unique ID:

Claimant Information:

Claimant Type:

Parent/Guardian Information:

Contact Information: