Fix a Claim | ICCU Data Breach Litigation

Deficiency Reasons

Please use the upload tool below to provide documentation to rebut the determination that:

ICCU Data Breach Claim Form

SECTION I – SETTLEMENT BENEFITS – WHAT YOU MAY GET

You may submit a claim for one or more of these benefits:

Cash Reimbursement. Use this claim form to request money for one or more of the following:

Reimbursement for Money You Spent. If you spent money trying to avoid or recover from fraud or identity theft because of the ICCU data breach, you can be reimbursed. You must submit documents supporting your claim.
Reimbursement for Money You Lost. If you lost money from fraud or identity theft because of the ICCU data breach, you can be reimbursed. You must submit documents supporting your claim.

Credit monitoring. Use this claim form to request free credit monitoring and identity restoration services through Kroll for twelve (12) months.

Additional Cash Payment. The additional cash payments will be calculated after all payments are made for Cash Reimbursement and will be an amount equal to a pro rata distribution of the Net Settlement Fund. You do not need to submit a claim to receive an Additional Cash Payment.

Please note: The Settlement Administrator may contact you to request additional documents to process your claim. Your cash benefit may decrease depending on the number of claims filed.

Settlement benefits will be distributed after the Settlement is approved by the Court and final. If you submit a claim, it will be maintained as confidential and not shared with ICCU.

SECTION II - YOUR INFORMATION

We will use this information to contact you and process your claim. It will not be used for any other purpose. If any of the following information changes, you must promptly notify us by emailing info@ICCUDataBreachSettlement.

First Name *

Middle Initial

Last Name *

Alternative Name(s)

Street 1 *

Street 2

City *

State *

Zip Code *

Telephone Number

Email Address *

* Denotes required fields.

SECTION III – CASH PAYMENT: MONEY YOU LOST OR SPENT

If you lost or spent money trying to prevent or recover from fraud or identity theft caused by the ICCU data breach and have not been reimbursed for that money, you can receive a reimbursement.

It is important for you to send documents that show what happened and how much you lost or spent, so that you can be repaid.

Examples of Loss Type and Documents	Amount and Date	Description of Loss or Money Spent and Supporting Documents (Identify what you are attaching, and why it’s related to the ICCU breach)
Examples of Loss Type and Documents Credit monitoring and identity theft protection purchased on or after 2/1/2020. Examples: Receipts or statements for credit monitoring services.	Amount and Date $ Date:	Description of Loss or Money Spent and Supporting Documents (Identify what you are attaching, and why it’s related to the ICCU breach)
Examples of Loss Type and Documents Costs, expenses, and losses due to identity theft, fraud, or misuse of your personal information on or after 2/1/2020. Examples: Account statement with unauthorized charges highlighted; police reports; IRS documents; FTC Identity Theft Reports; letters refusing to refund fraudulent charges; credit monitoring services you purchased.	Amount and Date $ Date:	Description of Loss or Money Spent and Supporting Documents (Identify what you are attaching, and why it’s related to the ICCU breach)
Examples of Loss Type and Documents Professional fees paid to address identity theft on or after 2/1/2020. Examples: Receipts, bills, and invoices from accountants, lawyers, or others.	Amount and Date $ Date:	Description of Loss or Money Spent and Supporting Documents (Identify what you are attaching, and why it’s related to the ICCU breach)
Examples of Loss Type and Documents Other expenses such as notary, fax, postage, copying, mileage, and long- distance telephone charges related to the data breach. Examples: Phone bills, receipts, detailed list of places you traveled (i.e., police station, IRS office), reason why you traveled there (i.e., police report or letter from IRS re: falsified tax return) and number of miles you traveled.	Amount and Date $ Date:	Description of Loss or Money Spent and Supporting Documents (Identify what you are attaching, and why it’s related to the ICCU breach)

If you spent money trying to avoid or recover from fraud or identity theft because of the ICCU data breach, you can be reimbursed. You must submit documents supporting your claim.

SECTION IV – CASH PAYMENT: TIME SPENT

If you spent time trying to recover from fraud or identity theft caused by the data breach, or if you spent time trying to avoid fraud or identity theft because of the data breach (for example, researching the breach, placing or removing credit freezes on your credit files, purchasing credit monitoring services, or taking other actions), complete the chart below. You can be compensated $25 per hour for up to forty (40) hours.

You must describe the actions you took in response to the data breach and the time each action took.

How much time did you lose related to the data breach?
(Do not answer this question if you are not claiming lost time.)

Hours

Minutes

By filling out the boxes below, you are certifying that the time you spent doesn’t relate to other data breaches.

Explanation of Time Spent (Identify what you did and why)	Approx. Date(s)	Number of Hours and Minutes
Explanation of Time Spent (Identify what you did and why)	Approx. Date(s)	Number of Hours and Minutes Hours : Minutes
Explanation of Time Spent (Identify what you did and why)	Approx. Date(s)	Number of Hours and Minutes Hours : Minutes
Explanation of Time Spent (Identify what you did and why)	Approx. Date(s)	Number of Hours and Minutes Hours : Minutes

If you lost money from fraud or identity theft because of the ICCU data breach, you can be reimbursed. You must submit documents supporting your claim.

SECTION V – HOW YOU WOULD LIKE TO RECEIVE YOUR CASH PAYMENT

If you made a claim for a cash payment in this claim form, you can elect to receive your payment either by check or electronically by PayPal or Venmo. Checks must be cashed within 180 days from the issue date.

Which do you prefer?

Check

PayPal

PayPal email address

Venmo

Venmo phone number

SECTION VI – WOULD YOU LIKE TO RECEIVE CREDIT MONITORING SERVICES

Would you like to enroll in Credit Monitoring and Identity Restoration Services from Kroll at no cost to you? You can elect to enroll in Credit Monitoring and Identity Restoration Services regardless of whether you also submit a claim for cash payment.

Yes

Email Address to receive Credit Monitoring

SECTION VII - DOCUMENTATION

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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SECTION VII – SIGNATURE

I affirm under the laws of the United States that the information supplied in this claim form is true and correct to the best of my knowledge and that any documents that I have submitted in support of my claim are true and correct copies of original documentation.

I understand that I may be asked to provide more information by the Settlement Administrator before my claim is complete.

Signature *

Date

In re: ICCU Data Breach Litigation

Case No. CV03-20-00831

Sixth Judicial District Court for the State of Idaho

ICCU Data Breach Claim Form

Your Deficiency Response has been submitted successfully.

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Confirmation Code:
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CLAIM INFORMATION
First Name
Middle Initial
Last Name
Street 1
Street 2
City
State
Zip Code
Telephone Number
Email Address