Submit a Claim Form - Instructions

This Claim Form should be filled out online or submitted by mail if you had either documented unreimbursed out-of-pocket expenses fairly traceable to the Security Incident or you wish to receive an alternative cash payment, and you wish to receive twelve (12) months of credit monitoring. Checks will be mailed, or electronic payments will be made, to eligible Settlement Class Members if the Settlement is approved by the Court.

Complete information about the Settlement and Settlement Benefits are available in the Notice and on the Frequently Asked Questions (FAQs) page of this website.

Claim Forms must be submitted online or postmarked (if mailed) no later than September 15, 2025. Claims submitted after the deadline will be deemed untimely and may not be accepted.


Documentation:

If you plan to make a claim for reimbursement of Ordinary Losses, Extraordinary Losses, and/or Lost Time, documentation must be provided to support your claim. Documents should be clear, readable copies, as anything you submit will not be returned to you. You may redact unrelated transactions and all but the first four and last four digits of any account number (if applicable).

If you are filing online, please have this information ready before you start to file, as your claim will not be saved if you have to come back and finish at a later time. Documents that are uploaded must be less than 20 MB per file and in one of these formats: jpg, jpeg, png, gif, tif, tiff, doc, docx, xls, xlsx, pdf, txt, rtf, or zip. If you are unable to electronically upload a copy of your documents as part of the online Claim Form, you will need to mail a printed Claim Form along with your documentation to the Settlement Administrator.

Please Note: The Settlement Administrator may contact you to request additional documents to process your claim. Settlement benefits will be distributed after the Settlement Agreement is approved by the Court and becomes Final.


How to File Online

Before Claim Filing:

Unique ID required for closed class: You will need the Unique ID printed on the Postcard Notice that you received in the mail. If you did not receive a Postcard Notice or have lost yours, please contact the Settlement Administrator at info2@AmbulnzSettlement.com or 1-888-867-7175 for assistance.

During Claim Filing:

Specific Claims Made: As part of filling out your Claim Form, you will be asked to verify your personal information and any specific claims you are asserting. Settlement Class Members may submit a claim using the Claim Form for: (1) 1 year of credit monitoring; (2) Ordinary Loss Claims – up to a total of $400 per claimant; (3) Lost Time - $18.50 per hour for up to 4 hours (for a total of $74,); and (4) Extraordinary Loss Claims - up to a total of $4,500 per claimant. Alternatively, Settlement Class Members may submit a claim for an Alternative Cash Benefit of either $30 or $10 per claimant, depending on whether Ambulnz’s records reflect that their Social Security number or driver’s license number was implicated in the Security Incident.

You must also submit all required supporting documentation such as receipts for fees paid and descriptions of lost time. Supporting documentation should be clear, readable copies, as they will not be returned to you. Please keep copies of everything you submit, as your claim may be audited, and you could be asked to provide additional information to process the claim.

After Claim Filing:

Confirmation Code:

After submitting your completed claim online, you will receive an email with a confirmation code for your completed submission. Be sure to keep your confirmation email and code and refer back to them if you have any questions about your Claim Form.



How to File by Mail

If you wish to submit a Claim Form via standard mail, you may download a copy of the Claim Form here. You will need to provide all the information requested on the Claim Form (remembering to sign and date it), attach any supporting documentation, and then mail it to the following address:

Ambulnz Security Incident
Settlement Administrator
P.O. BOX 2856
PORTLAND, OR 97208-2856

Remember: All Claim Forms must be submitted online or postmarked no later than September 15, 2025.