Goetz v. Benefit Recovery Specialists, Inc.

Case No. 20 CV 550

Walworth County Wisconsin Circuit Court

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).

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

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ELECTION FORM

The deadline for submitting this election form is July 29, 2022

The Settlement Class is defined as all persons whose personal information and/or protected health information was compromised in Benefit Recovery Specialists Inc.’s Data Breach. You may submit this Election Form only if you are a Settlement Class Member in the above action.

As a member of the Settlement Class, if you do not submit a timely request for exclusion from the Settlement Class, you are entitled to obtain coverage under IDX’s plan for a two-year period at BRSI’s cost.

Settlement Class Members who elect to receive coverage under IDX’s plan will receive enrollment information for coverage under IDX’s plan for a two-year period.

To elect the IDX plan, please provide the following information:

Provide Your Contact Information:
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Recieved Services and Dates










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Fill Out and Sign the Following Attestation:

I want to ENROLL in IDX’s plan for a two-year period at BRSI’s cost. I declare under penalty of perjury that I am a Settlement Class Member and that the information provided below is true and accurate.

Your Claim Form has been submitted successfully.

HOWEVER, it appears one or more of the documents you uploaded were not successfully received. Please see below for which file(s) had errors and log back in to your existing Claim online to re-upload your document(s). Alternatively, you can send your documents with your Submitted Claim ID to the Settlement Administrator by email to: Info@BenefitRecoverySettlement.com.

Please print this page for your records.

Your Claim Details

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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
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Date

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

Click here to edit your Claim.