Kalima Lawsuit - Information Request Form

Information Request Form - Page 1

Please use this form to provide current information for living Settlement Class members and deceased Class Member's family representatives and family members.

Submitter Information:

Please select who is submitting this form:*

Class Member
Representative of Class Member

Please Note: Representatives of Class Members will serve as the point of communication during the processing of the Class Member's claim. Being appointed as a representative does not entitle the appointed person to receive any settlement proceeds that are awarded to the claim.

Class Member Information:

First Name:*

Middle Initial:

Last Name:*

Date of Birth:*

Note: If you do not know the exact day of birth, please select the 1st (Example: 05/01/2000).

Last 4 Digits of SSN:*

Representative Information:

To complete this form on behalf of the Class Member, please answer the following questions.

1. Who is the Class Member being represented by?*

The Class Member has a will.
The Class Member has a trust.
The Class Member has neither a will nor a trust.
It is not known if the Class Member has a will and/or a trust.

First Name:*

Middle Initial:

Last Name:*

Executor/Trustee Name:*

2. What is your relationship to the Class Member?*

Please provide a what type of relationship you have with the Class Member.*

3. Why you are submitting this information on behalf of the Class Member?*

The Class Member is incapacitated or is lacking capacity.
The Class Member is deceased.
The Class Member is neither deceased nor incapacitated.

Date of Death:*

Estate EIN:

Contact Information:

All communications from the Claims Administrator will be directed to the information provided below.

Country:*

Address Line 1:*

Address Line 2:

City:

Province/Region:

Postal Code:

City:*

State:*

Province:*

ZIP Code:*

Postal Code:*

Phone Number:*

Email Address: