Step 1 of 10 10% This field is hidden when viewing the formhidden claimant id*This field is hidden when viewing the formhidden last name* CLAIM FORM Meyers, et al. v BHI Energy Services, LLC. et al. Case No. 1:23-cv-12513-LTS If you are a resident of the United States and were sent a notice letter from BHI Energy Services, LLC and BHI Energy I Specialty Services LLC (“BHI” or “Defendants”), which was not returned as undeliverable and which notified you that your Private Information may have been compromised in a data breach incident (the “Data Incident”) between May 30, 2023 and July 7, 2023, use this form to make a claim for documented Out-Of-Pocket Losses, reimbursement of Lost Time, CCPA Payment, Identity Theft Protection, Credit Monitoring Services, and a one-time Pro Rata Cash Payment. GENERAL INSTRUCTIONS. If you fit the above description and are a member of the Settlement Class, you are eligible to complete this Claim Form to request reimbursement for documented Out-Of-Pocket Losses as a result of the Data Incident up to a maximum of $7,500 per person, compensation for up to 4 hours of Lost Time at $25 per hour for time spent reasonably related to mitigating the effects of the Data Incident, $100 CCPA Payment for California Subclass Members only, two (2) years of three-bureau Identity Theft Protection and Credit Monitoring Services, and a Pro Rata Cash Payment. Please read the Claim Form carefully and answer all questions. Failure to provide the required information could result in a denial of your claim. This Claim Form can be completed and submitted with the required documentation or mailed to the address below. Claim Forms must be submitted on or before June 12, 2025. Please legibly print all requested information, in blue or black ink. Submit your Claim Form online, or mail your completed Claim Form, including any supporting documentation, to the address below. Documentation provided in support of your claim will not be returned, please retain copies of your documents for your personal records. BHI Energy Services Data Breach Settlement c/o Atticus Administration PO Box 64053 St. Paul, MN 55164 CLASS MEMBER NAME AND CONTACT INFORMATIONProvide your name and contact information below. You must notify the Claims Administrator if your contact information changes after you submit this form. NAME:* First Name Last Name Mailing Address* Mailing Address CITY: AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Zip Code This field is hidden when viewing the formCheck if address is non-US Please check if this is a non-U.S. address Email Address* Telephone Number* PROOF OF CLASS MEMBERSHIPI certify that I reside in the United States and received notice from BHI that my private Information may have been compromised in a data breach incident between May 30, 2023, to July 7, 2023 (“Settlement Class Member”).* YES NO I certify that I reside in the State of California and am a California Subclass Member and received notice from BHI that my Private Information may have been compromised in a data breach incident between May 30, 2023, to July 7, 2023 (“California Subclass”).* YES NO Notice ID Number* IDENTITY THEFT PROTECTION AND CREDIT MONITORING SERVICESCredit Monitoring Checkbox Check this box if you wish to receive two (2) years of Identity Theft Protection and Credit Monitoring Services OUT-OF-POCKET LOSSESComplete this section of the Claim Form to be reimbursed for documented Out-Of-Pocket Losses that you incurred as a result of the Data Incident, up to a maximum of $7,500. Documentation to substantiate your claim(s) is required and must accompany your Claim Form. Class Member must submit reasonable documentation that these expenses claimed were incurred as a result of the Data Incident and not otherwise reimbursed by another source. This documentation may include receipts or similar documentation that documents the costs incurred. “Self-prepared” documents, such as handwritten receipts, are insufficient for reimbursement, but may be considered by the Claims Administrator to add clarity or support for a Settlement Claim.Ordinary Out-of-Pocket Checkbox Check this box if you are seeking reimbursement for documented out-of-pocket Losses. Documented Ordinary Losses Table*Out-of-Pocket Loss DescriptionDateDollar AmountSupport Documentation Description Supporting Documents for OUT-OF-POCKET LOSSES* Drop files here or Select files Accepted file types: pdf, jpg, jpeg, bmp, png, docx, doc, xlsx, xls, Max. file size: 16 MB. To qualify for Out-Of-Pocket Loss Reimbursements, documentation must be provided for each claimed Out-Of-Pocket Loss listed above. LOST TIMEComplete this section of the Claim Form to receive compensation for up to four (4) hours of Lost Time at $25 per hour for time spent reasonably related to mitigating the effects of the Data Incident.Lost Time Checkbox Check this box if are seeking reimbursement for time spent dealing with the Data Incident and indicate how many hours of lost time you spent: I am claiming Lost Time in the total hours (rounding up to the next hour) indicated below:**** Select an Answer ***1 Hour ($25)2 Hours ($50)3 Hours ($75)4 Hours ($100)Lost Time Attest Checkbox* I attest and affirm to the best of my knowledge and belief that any claimed Lost Time was spent reasonably related to mitigating the effects of the Data Incident. CCPA PAYMENTComplete this section of the Claim Form if you are a California Subclass Member seeking the CCPA Payment Benefit. I attest and affirm to the best of my knowledge and belief that I am a California Subclass Member and would like to claim the pro rata $100 CCPA Payment Benefit. I attest and affirm to the best of my knowledge and belief that I am a California Subclass Member and would like to claim the pro rata $100 CCPA Payment Benefit. PRO RATA PAYMENTComplete this section of the Claim Form if you are a Settlement Class Member and are seeking the Pro Rata Cash Payment Benefit. I attest and affirm to the best of my knowledge and believe that I am a Settlement Subclass Member and would like to claim the pro rata Cash Paymen I attest and affirm to the best of my knowledge and believe that I am a Settlement Subclass Member and would like to claim the pro rata Cash Payment. Benefit Selection Summary Please review your selected benefits below. You may go back and make any changes, or continue onto the payment selection portion of the claim form. * Theft Protection and Credit Monitoring Services*OUT-OF-POCKET LOSSES*LOST TIME*CCPA PAYMENT*PRO RATA PAYMENTNo Benefits radio button You have not selected any claim benefits. Please go back and select at least one claim benefit to proceed. PAYMENT SELECTIONPlease select one payment method for receipt of any Settlement payment to which you are determined eligible Payment Method*This field is hidden when viewing the formPayment Token* YOU WILL RECEIVE A VERIFICATION EMAIL REGARDING YOUR DIGITAL PAYMENT. YOU MUST VERIFY AND AUTHENTICATE YOUR PAYMENT INFORMATION IN ORDER TO RECEIVE A DIGITAL PAYMENT. IF YOU DO NOT VERIFY AND AUTHENTICATE YOUR INFORMATION, A PAPER CHECK WILL BE SENT TO YOU. ATTESTATION & SIGNATURESignature checkbox* I swear and affirm under the laws of my state 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. Printed Signature*Date* MM slash DD slash YYYY PLEASE MAKE SURE YOUR CLAIM FORM IS COMPLETE, SIGNED, AND INCLUDES DOCUMENTATION TO SUPPORT ANY OUT-OF-POCKET LOSSES BEING CLAIMED. THE CLAIM FORM MUST BE POSTMARKED FOR MAIL OR SUBMITTED ONLINE ON OR BEFORE JUNE 12, 2025. Unique IDClaimFormNoEmailThis field is for validation purposes and should be left unchanged.
