HHS BIPA SETTLEMENT CLAIM FORM

This claim form must be submitted online or postmarked by October 7, 2021 and must be fully completed, be signed, and meet all conditions of the Settlement Agreement.

Before you complete and submit this Claim Form, you should read and be familiar with the information contained in the notice and FAQs. The Settlement Administrator will review your Claim Form; you may be required to submit additional documentation to validate your claim. If accepted, you will be mailed a check for $950 or, if certain conditions are met, a pro rata share of the Net Settlement Fund, which may be less than $950. This process takes time. Please be patient.

Instructions: Fill out each section of this form and sign where indicated.

Address Where You Lived When Working For Hospital Housekeeping Systems, LLC (if different)

(You may be contacted if further information is required.)


Class Member Verification: By submitting this claim form and checking the boxes below, I declare that I believe to the best of my knowledge, information and belief that I am a member of the Settlement Class and that the following statements are true (each box must be checked to receive a payment):

I worked for Hospital Housekeeping Systems, LLC in the State of Illinois between November 30, 2015 and November 30, 2020, and had my Biometric Identifiers and/or Biometric Information collected, captured, received, or otherwise obtained or disclosed by Hospital Housekeeping Systems, LLC or its agent(s).

I have not filed for an Opt-Out or to be excluded from this Settlement.

I have not submitted any other Claim for the same account, have not authorized any other person or entity to do so on my behalf, and know of no other person or entity having done so on my behalf.

Under penalty of perjury, all information provided in this Claim Form is true and correct to the best of my knowledge, information and belief.