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).

If you did not receive a personalized Notice in the mail or via email, click below to complete a Claim Form.

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

THE DEADLINE TO SUBMIT THIS CLAIM FORM IS:

If you were notified that your private information (“Personal Information”) was potentially impacted in the Data Security Incident that Fertility Centers of Illinois, PLLC (“FCI”) publicly announced on December 27, 2021, where FCI’s internal systems were the target of an external criminal-cyberattack, you are a “Class Member.” The Settlement, if approved by the Court will provide 24-months of Financial Shield services to all Class Members who enroll, reimburse Class Members for out-of-pocket losses and lost time researching and remedying the effects of the Data Security Incident, and pay Class Counsel’s attorneys’ fees, costs, and expenses, and provide a service award for each of the Representative Plaintiffs.

As a Class Member, you may be eligible to receive up to $450 total for ordinary losses, including up to $80 in reimbursement for lost time incurred as a result of the Security Incident (“Out-of-Pocket Losses”), and up to $5,000 reimbursement for extraordinary losses, proven monetary losses that are reasonably and fairly traceable to the Security Incident (“Extraordinary Losses”). You will also be provided with access to Financial Shield services by Pango for a period of 24 months from the Effective Date of the Settlement.

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.

Cash payments amounts may be reduced pro rata (proportionately) depending on how many people submit such claims. Additional payments may also be sent. Complete information about the Settlement and its benefits are available at this website.

This Claim Form may be submitted electronically via this Settlement Website or completed and mailed to the address below. Please type or legibly print all requested information, in blue or black ink. Mail your completed Claim Form, including any supporting documentation, by U.S. mail to:

FCI Data Security Incident Settlement 1650 Arch Street, Suite 2210 Philadelphia, PA 19103

II. CLAIMANT INFORMATION

The Settlement Administrator will use this information for all communications regarding this Claim Form and the Settlement. If this information changes prior to distribution of approved reimbursements, you must notify the Settlement Administrator in writing at the address above.

* Required Fields

III. REIMBURSEMENT FOR OUT-OF-POCKET LOSSES

You may seek reimbursement for up to $450 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 Data Security Incident.

As part of your claim for Out-of-Pocket losses, you may also make a claim for up to four (4) hours of lost time, compensated at $20/hr., for a total of up to $80, for time spent dealing with the Data Security Incident.

Cost Type
(Fill all that apply)		 Approximate Date of Loss Amount of Loss
Unreimbursed fraud losses or charges
$
Description of Supporting Documentation (Identify what you are attaching and why):
Examples: Account statement with unauthorized charges highlighted; Correspondence from financial institution declining to reimburse you for fraudulent charges
Professional fees incurred in connection with identity theft or falsified tax returns
$
Description of Supporting Documentation (Identify what you are attaching and why):
Examples: Receipt for hiring service to assist you in addressing identity theft; Accountant bill for re-filing tax return
Lost interest or other damages resulting from a delayed state and/or federal tax refund in connection with fraudulent tax return filings
$
Description of Supporting Documentation (Identify what you are attaching and why):
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
Credit freeze
$
Description of Supporting Documentation (Identify what you are attaching and why):
Examples: Notices or account statements reflecting payment for a credit freeze
Credit monitoring that was purchased between December 27, 2021, and September 23, 2022
$
Description of Supporting Documentation (Identify what you are attaching and why):
Examples: Receipts or account statements reflecting purchases made for Credit Monitoring & Insurance Services
Miscellaneous expenses such as notary, fax, postage, copying, mileage, and long- distance telephone charges
$
Description of Supporting Documentation (Identify what you are attaching and why):
Examples: 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
Other (provided detailed description)
$
Description of Supporting Documentation (Identify what you are attaching and why):
Please provide detailed description below or in a separate document submitted with this Claim Form
Time Expenditures: Hours for time spent dealing with the Security Incident
Hours claimed(up to 4 hours)
Description of Supporting Documentation (Identify what you are attaching and why):
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 $5,000 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 Data Security Incident; (iii) the loss occurred between February 1, 2021 and the Claims Deadline; (iv) the loss is not already covered by one or more of the ordinary 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. Please provide an itemized list of any Extraordinary Losses below, if you need additional lines, you may submit additional pages containing this information with your claim:

Cost Type Approximate Date of Loss Amount of Loss
$
Description of Supporting Documentation (Identify what you are attaching and why):
$
Description of Supporting Documentation (Identify what you are attaching and why):
$
Description of Supporting Documentation (Identify what you are attaching and why):
$
Description of Supporting Documentation (Identify what you are attaching and why):
V. Upload Supporting Documentation

Accepted file types are: DOCX, DOC, XLS, XLSX, 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. Payment Method

    You have successfully requested a payment. Click here if you would like to choose a different payment method.

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


    [Signature]

    Your Claim Form has been submitted successfully.

    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
    Last Name
    Street Address
    Street Address 2
    City
    State
    Zip Code
    Email Address
    Phone Number
    Date

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

    Click here to edit your Claim.

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