ATTENTION: This Claim Form is to be used to apply for monetary benefits from the settlement of a lawsuit with Mercy Hospital, Iowa City, Iowa ("Mercy"). The lawsuit alleges that Mercy received a phishing e-mail in May and June 2020, which resulted in the potential compromise of patients’ and guarantors’ private information ("Data Incident"). To recover as part of this settlement, you must provide the information requested in this Claim Form for each applicable claim. PLEASE BE ADVISED that any documentation you provide must be submitted with this Claim Form.

You may submit claims in each applicable category below:

(A) Compensation for ordinary losses attributable to the Data Incident, which include (1) unreimbursed losses relating to fraud or identity theft; professional fees including attorneys’ fees, accountants’ fees, and fees for credit repair services; costs associated with freezing or unfreezing credit with any credit reporting agency; credit monitoring costs that were incurred on or after May 15, 2020, through the date of preliminary approval; and miscellaneous expenses such as notary, fax, postage, copying, mileage, and long-distance telephone charges and up (2) up to six (6) hours of lost time (at $20 per hour) comprised of 3 hours attested and up to an additional 3 hours with documentation provided that you certify the lost time was spent in response to the Data Incident

(B) Compensation for extraordinary losses attributable to the Data Incident, including out-of-pocket costs associated with identity theft, tax fraud, other forms of fraud, and other actual misuse of personal information as a result of the Data Incident.