Menu Zamknij

wells fargo class action lawsuit 2021 claim form

The schedule for the final hearing is on July 22, 2021. The check will be sent to the address on the claim form. Go on and tell us about your poor consumer experience. The settlement details have been released recently on several outlets online, and we here at Consider The Consumer are more than happy to provide you with the key information to know about. : 8:18-cv-00332, Jurisdiction:United States District Court for the Central District of California, Products/Services Involved:Wells Fargos auto loan car insurance. About Us This settlement is currently Read More, Electrolux Home Products Inc. Agrees To Compensate Consumers Amid Class Action Suit According to the class action lawsuit, some of Electroluxs dryers had defects that could lead to fires. Learn more about the cookies we use. Wells Fargo Merchant Services has not acknowledged any wrongdoings or any of the allegations against them. Found out it was leaked to the dark web in December 2021. May 8. About Us Please add me Ive been used Wells Fargos ATM machines for 3 years and I was wondering why there was so much money charged forget to cash out. This field is for validation purposes and should be left unchanged. Actions does not process claims and we cannot advise you on the Scammed me also. People you have to fill out a application to be added.not by simply saying add me!!! I have been a Wells Fargo customer since 1983. Id like to be added. Up to $40 million, Law Firms: Lieff Cabraser Heimann & BernsteinWebb Klase & Lemond LLC, Claim Form: Wells Fargo Merchant Services Charges Settlement Claim Form, Case Name: As of April 11,2023 the website states that the settlement will be distributed in June 2023. Please add me, other that period I had chase, BOA, and wells fargo accounts with out of network fees applied to each. The AT&T settlement I cant remember my phone number. Beyond TRID: Safeguarding compliance on every loan, Opinion: Setting the record straight on mortgage pricing, Mortgage fintech Maxwell launches SSO tool for lenders, Recognizing ROI: Improve Margins with a Connected Transaction, A guide to optimizing client engagement and communication. Editor's Note on Armando Herrera Settlement 2021 - Wells Fargo To Settle GAP Insurance Class Action Lawsuit For $500 Million: Wells Fargo has agreed to pay $20 million in June 2020 to settle allegations that the company did not grant loans to individuals with "Deferred Action for Childhood Arrivals.". Aside from paying out the compensation, the company has also agreed to update the terms of their payment processing services/. A settlement has been approved resolving claims by Former and Current Participants in the Wells Fargo & Company 401 (k) Plan (the "Plan") who invested in certain Plan investments ("Challenged Funds") since March 13, 2014 through the date on which the Settlement becomes Final. so she was also unaware that these hackers were contacting her contacts and she didnt even know she had been hacked ormmand no one contacted her or anything who knows how who else or how many other peoples information they got or how many more people they scammed! Top Class Actions is a legal news source Ya never know. Case Name(s) & No. However, this can result in some functions no longer being available. Claimants in the Armando Herrera et al. Is this for real? Go on and tell us about your poor consumer experience. Wells Fargo and an insurance company it worked with have agreed to pay $432 million to settle a class-action lawsuit brought by customers who say they were charged premiums for auto . Hello, I had received a few different letters-one from Facebook, T mobile, and In home supportive services, all saying that my data was breached. Plaintiffs are seeking to have their losses restored that they suffered from being in funds that performed poorly, she said. According to a class action lawsuit against the settling companies and other organizations, consumers incurred unfair ATM surcharges when using out-of-network ATMs. 8:17-ML-2797-AG-KES Home Espaol Welcome to the Informational Website for the Wells Fargo CPI Class Action Settlement. If you havent figured it out by now that there is no list and if there were one, how would someone add your information to the list? Other related legal fees such as attorney fees, legal costs, and others will be paid separately by Wells Fargo. Multinational financial services company, Wells Fargo, will pay out $40 million to resolve claims regarding their merchant services. Assets in Wells Fargos plan increased by $8.3 billion from 2016 to 2019, the most recent year for which data is available, Judy Diamonds research shows. Radius Health, Inc. Investigation Shareholders Potentially Harmed By Merger Terms, Aon PLC Data Breach Investigation Personal Identifiable Information Of Over 145,000 Individuals Exposed, Certain Walmart Brand Great Value Spices Found to Contain Heavy Metals. Multinational financial services company, Wells Fargo, will pay out $40 million to resolve claims regarding their merchant services. Rehoboth McKinley Christian Health Care Services data breach class action settlement. A class action lawsuit alleged Wells Fargo improperly collected the cost of GAP insurance coverage when certain loans were paid off early. The bank's executives selected 17 proprietary funds for the retirement plan. hbbd```b``.@$- d&X|3X|=\&M`?0?f//$3 # f}N2)0&F~TH|0 lA} Wells Fargo should have been able to obtain superior investment products at low cost but chose proprietary products, the lawsuit says. The final approval hearing for the JP Morgan, Wells Fargo, and Bank of America out-of-network ATM fees class action lawsuit settlement is scheduled for May 17, 2022. Wells Fargo Merchant Services Charges Settlement Claim Form, Wells Fargo Merchant Services Charges Settlement Website. Nelnet Servicing Data Leak Your Personal Information At Risk! document.getElementById( "ak_js_5" ).setAttribute( "value", ( new Date() ).getTime() ); @2023 Top Class Actions. Your email address will not be published. The merchant has done any of the following: Processed sales through the fixed pricing plan, Monthly processing fee or non-validation payment card industry (PCI) compliance fee, Processed sales using other plans (except for the standard pricing plan), The merchant is not account managed within the class period. He noted that from the CFPBs amicus brief it becomes clear that the bureau intended to expand the scope of qualified written requests. Customers can file for objections and exclusions until June 8, 2021. Please add me. I just learned that Tmobile leaked my ssn and other data. Wells Fargo Knowingly Aided 'Risk-Free' Trial Scams, Class Action Lawsuit Alleges. Id love to be part of this. Rodan + Fields, an American manufacturer of skincare products, has entered into a $38M settlement with consumers over claims that its Lash Boost product contains dangerous and severe side effects. St Lucie county? McCoy and Olivera claim they did not receive the information that they asked for. Millions of Wells Fargo customers are in line for relief money after the government found the banking giant violated a host of federal consumer laws between 2011 and 2022. In addition to these allegations, it is also Read More, Chipotle Consumers Entitled To Award After Settlement Resolves Misrepresentations Regarding Delivery, Service Fees Chipotle App or Website users may be entitled to a cash award after a settlement was reached with the company regarding misrepresentations of delivery fees, service fees, and prices on delivery orders. Payment by check, according to the allocation plan set forth in the Notice. v. case take heed! The Consumer Financial Protection Bureau chimed in on an appeal to the McCoy vs. Wells Fargo Bank case, arguing that a borrower should be able to get information about their loan from their loan servicer. Send us your story with as much detail as possible to fill out our investigation. You must contact the This settlement is currently Read More, Electrolux Home Products Inc. Agrees To Compensate Consumers Amid Class Action Suit According to the class action lawsuit, some of Electroluxs dryers had defects that could lead to fires. The CFPB said the alleged oversight amounted to a failure to comply with the Real Estate Settlement Procedures Act (RESPA) and Regulation X, which the agency has jurisdiction over. I have used both Atms with J P Morgan Chase & v. Wells Fargo Merchant Services, LLC, Settlement Website: Wells Fargo Merchant Services Charges Settlement Website. Experian, T-Mobile data breach $16M class action settlement. Wells Fargo Merchant Services, LLC will pay up to $40 million to settle a class action alleging it added excessive charges to merchants monthly invoices. Seems like a lot of things ordered through AMAZON is theft when you order 1 item and they send you 2 and bill you gfor 2. Site by, Mike Darne on how lenders can use credit to win more business and improve profitability, Blend CEO on the firms runway, vision and shifting priorities, Logan Mohtashami on why the foreclosure fanatics are wrong (again), CHLA supports changes to CFPB loan originator compensation rule, CFPB proposes rule to bolster PACE loan borrower protections. Please review our Affiliate Link Disclosure for more information. Most recently, the CFPB warned that it is closely monitoring how servicers conduct themselves to help borrowers avoid foreclosures. hVn8>vQxy/P5P'4(l,TIA_u,>l I do not care about rule 23. Without this alleged agreement, consumers would have paid significantly less in fees, the class action lawsuit contends. Rodan + Fields Lash Boost Contains Serious Side Effects $38M Class Action Settlement, StubHub, Inc. Settles Lawsuit Alleging Violations of Consumer Protection Laws, Electrolux Dryer Class Action Settlement Reports Of Fires From Lint Buildup, Chipotle Mexican Grill, Inc. Settlement Delivery, Service Fees Misrepresented. Please add me I have been with Wells Fargo since that took over Wachovia Bank. Mail.com NOTE: If you do not qualify for this settlement do NOT file a claim. Wells Fargo ended up agreeing to select conditions set upon by the settlement agreement presented to them. So thats false. Profit from our disability checks, from medical card billings for care we never received, the state check for our care, the profit from the land we were forced to clear, food stamps for our food that they would eat, we got none of. This field is for validation purposes and should be left unchanged. I do not know when this happened as I did not have any knowledge my information was out there until i paid for google to do a dark web report for me last week. We use cookies to improve functionality and performance, enhance user experience, and provide tailored content. I did get reimbursed ONE time after I complained about going to an ATM, my card wouldnt work, then went across street to another bank, no problem, to withdraw money, then charged altogether $6.00. 8:18-cv-0032. THANKS! 1-866-759-6521 RESPA, which was originally passed in 1975, and most recently amended in 2008, requires mortgage servicers to respond to borrowers seeking information about a mortgage loan within 10 business days. The lawsuit also claimed that after Wells Fargo received qualified written requests in the form of a notice of error, it did not investigate the errors as required by Regulation X. Gmail.com Wells Fargo GAP Insurance Class Action Revisited, It is worth noting that Wells Fargo has agreed to shell out $500 million as the main settlement fund to end the, Wells Fargo GAP Insurance Class Action Settlement Agreements Key Details, Listed below are some of the key details one should know to be abreast of the latest developments in the. I had to investigate independently to find out I had been a victim of scam investment in coinbase app . Update: Per the Distribution Order, initial payments went out to Authorized Claimants for this matter in September 2020. May 9. Listed below are some of the key details one should know to be abreast of the latest developments in theWells Fargo GAP Insurance Settlement. Learn more about the cookies we use. This measly fee that they (banks) are paying back is just a drop in the bucket compared to the amount that they really have charged me over the years, like a fool I continue to use banking instead of putting my money in safe hiding place. its been about 45 days since final approval. How can I find out if my check is being sent out, I was supposed to get a $750 settlement last March by mail havent received anything. However, this can result in some functions no longer being available. In a blog posted on the CFPBs website this week, Seth Frotman, general counsel for the bureau, argued that Wells Fargos reasoning for not responding to the plaintiffs was not justified. Radius Health, Inc. Investigation Shareholders Potentially Harmed By Merger Terms, Aon PLC Data Breach Investigation Personal Identifiable Information Of Over 145,000 Individuals Exposed, Certain Walmart Brand Great Value Spices Found to Contain Heavy Metals. , respectively, in the United States by assets for 2021, according to Insider Intelligence. If you dont qualify for this settlement, check out our database of other open class action settlements you may be eligible for. CX Matiash AP. When our oldest daughter moved to Greenville,NC to finish school, I was struggling, with 3 other kids, one helpless with cerebral palsy and at that time and from then on, my husband was working at 74 years old to provide formal educations for our children all the while why at the time it was then un-descovered that he had multiple service connected illnessess from serving in the Air Force and was just starting to get compensation when we got a stage 4 metastatic esophageal cancer due to what we just learned that most likely is from his Phillips c-pap/bi-pap machine that after 5 years I still have, including the defective filters in the machine as well as an additional pack of 2 refills. Consumers who paid an unreimbursed ATM access fee directly to the defendants (JP Morgan, Wells Fargo, or Bank of America) or others (any bank that is a member of the Visa or MasterCard networks) for an out-of-network ATM transaction between Oct. 1, 2007, and Nov. 12, 2021. Please help me, with sincere thanks, Catherine D Earls. Housing Wire sat down with Newbold Advisors Partner Robert Simpson to learn more mortgage claims in todays servicing climate. v. Visa Inc., et al., Case No. Many class action lawsuit settlements have closing or exclusion deadlines during May. From the first day I was aware of a credit or debit card and learn that charges to get your own hard earned money out of one of this machines or monthly charges from a bank to get money out of my account I knew this day would come. Wed love to hear back from you. status of any class action settlement claim. The defendants allegedly worked together in an antitrust agreement to raise the cost of out-of-network ATM surcharges, resulting in artificially high costs for their customers. Taking this information, will will help rectify you complaint! that reports on class action lawsuits, class action settlements, Additional compensation that will be computed based on the maturity rate figures will also be added to the settlement checks eligible Class members can receive. payments should be going out fairly soon, shouldnt they? Can u send me another. The lead plaintiffs claim that the extra charges on the businesses monthly invoices have significantly impacted their profit. Yes a family friend was hacked via Facebook or Facebook Messenger theyre basically one of the same and I knew that messenger was not a safe platform._ And now because of this, they had her complete contact list. Wells Fargo & Company is an American multinational financial services company with a significant global presence. According to court documents, the claim submission deadline has passed. Wells Fargos plan had $48.2 billion in assets with 340,353 total participants as of year-end 2019, according to Judy Diamond Associates, a business unit of ALM Media (which is the parent company of ThinkAdvisor). HW Media connects and informs decision makers across the housing economy. c/o Rust Consulting Inc. 7182 document.getElementById( "ak_js_5" ).setAttribute( "value", ( new Date() ).getTime() ); @2023 Top Class Actions. drug injury lawsuits and product liability lawsuits. There many times when I had to use out of network ATMs because there wasnt any Chase banks within my reach. by Corrado Rizzi 2017 I dont know what to do either. expected to be mailed out. Save my name, email, and website in this browser for the next time I comment. JP Morgan, Wells Fargo, and Bank of America deny any wrongdoing but agreed to settle the claims against them in an out-of-network ATM fees class action settlement. I was charged extra fees by Wells Fargo. Decide which cookies you want to allow. This feature aims to report on the latest class action settlement Wells Fargo has decided to enter to end the legal difficulties it is facing in court in connection with the allegations of not returning their customers GAP insurance coverage. It decides to do that. The lawsuit alleges that the dryers contained defects that caused them to start fires due to lint buildup. They dont get to pick the funds in the 401(k) plan, so theyre relying on the fiduciaries of their plan to pick prudent and loyal options; and ERISA requires it.. Patti's Pitas, LLC and Queen City Tours filed the class action lawsuit against Wells Fargo Merchant Services, LLC, in August 2017 in a New York federal court. EVEN DR.S OFFICES AT LOMA LINDA REQUIRE YOU TO USE A COMPUTER FOR VIDEO VISITS WHICH IS TOTALLY UNFAIR TO POOR SENIORS WHO NEVER GREW UP IN COMPUTER AGE OR EVEN OWN A COMPUTER. If you received a Notice in the mail by or by e-mail from the settlement administrator for this case, Wells Fargo records show you are a class member. Dont forget you can visit MyAlerts to manage your alerts at any time. In January 2021, the bureau put the industry on alert, warning that it would direct its attention to how mortgage servicers were helping borrowers with COVID-19 forbearance. Fill out this form for a FREE and prompt case evaluation. TD Bank was targeted after Florida lawyer Scott Rothstein's more than $1 billion Ponzi scheme unraveled in 2009. Ive been trying to join that suit since 2013 Wells Fargo are blatantly stealing homes from customers and NOBODY wants to hold them accountable whatsoever! In the class action lawsuit filed on Jan. 31, 2021, in the U.S. District Court of Oregon, the two plaintiffs alleged that Wells Fargo failed to comply with the RESPA and Regulation X by. 30% of the settlement fund will be given to this class. Brought on behalf of participant Yvonne Becker inU.S. District Court for the District of Minnesota, theclass-action lawsuitasserts that some high-level executives at Wells Fargo who were named as the retirement plans fiduciaries selected and retained 17 Wells Fargo proprietary funds, many of which performed below the benchmark that the bank had picked as an appropriate broad-based market index for each Wells Fargo Fund., Becker further alleges that the Wells Fargo Funds included newly launched funds that lacked a performance history necessary to evaluate them, and that the Wells Fargo Funds charged greater fees than similar non-proprietary funds., Michelle Yau, a partner at Cohen Milstein in Washington and chair of thefirms Employee Benefits/ERISA practice group, who represents Becker and the other plaintiffs, told ThinkAdvisor in a recent interview that shes glad to see that Judge Donovan Frank, in denying Wells Fargos request to dismiss the case, understood why the case matters., Yau said: You have 350,000 current and former Wells Fargo employees who, for many of them, their only retirement savings is their 401(k) plan. Report Fraud The payment will also be mailed to the address they have put in the claim form. This website is not intended for viewing or usage by European Union citizens. I will be demanding compensation for the violation of my privacy. A Blueprint for Building an Enduring Practice, The suit also asserts that because of the enormous size of the plan, Wells Fargo should have been able to obtain superior investment products at very low cost but instead chose proprietary products to bolster their own salaries by increasing fee revenue and providing seed money to newly created Wells Fargo Funds., Wells Fargo doesnt have to have its high-level executives pick the funds for the plan, Yau told ThinkAdvisor. Wells Fargoagreed to pay $95.7 million to more than 5,300 home mortgage consultants to resolve a pair of class-action legal claims that allege wage-and-hour violations in California, according to the settlement agreement in federal court. They often notify the wrong parties. It is worth noting that Wells Fargo has agreed to shell out $500 million as the main settlement fund to end theWells Fargo GAP Insurance Class Action Lawsuitlitigation process. Furthermore, Plaintiffs' filed their Unopposed Motion for Preliminary Approval on August 2, 2021. https://topclassactions.com/wp-admin/admin-ajax.php. For information on deleting the cookies, please consult your browsers help function. N)t8P0@Z@V1202ae`Tbacbf\#F/2K\f A$@Ga CF% ` h$ However, they vehemently denied any misdeeds on their end. Payments from the JP Morgan, Wells Fargo, and Bank of America ATM fees lawsuit settlement will vary depending on a number of factors, including counsel and administrative fees and and other deductions from the settlement. But our Kroger charges me 50 cents if I want cash back. The CFPB filed its amicus brief on Monday, in a class action lawsuit before the Ninth Circuit Court of Appeals, alleging that Wells Fargo flouted its obligations to answer questions about two loans it serviced in 2020. I am upset and outraged if this is the same vreach and I can not get compensation when my life has been severly impacted by this? Another company out there in media retrieval is ZILKEE- THEY DID SAME THING TO MEORDERED ONE AND THEY SHOPPED AND BILLED ME FOR 2, THEN SAID I COULDNT RETURN 2ND ONE AT THE $60 PRICE EVEN AFTER I SHOWED THEM MY SCREENSHOT OF ACCEPTED ORDER. Is there any reason that you do not know that the case closed three weeks ago? Check out the list below to find out if you qualify to submit a claim! I received an email from them Sept 29th saying checks will be distributed soon havent heard from them since. Wells Fargo says it has already paid more than $33 million to Statutory Subclass Members between Feb. 22, 2019, and March 31, 2021, with individual payments averaging $316.87, according to the settlement agreement. A settlement with the U.S. Attorney General in December 2018 brought the total settlement cost to $3 billion. From student loans to unemployment it goes back even farther I knew they were over charging me but when you complained I was blew off, Please add me. Click Accept if you consent. What are your thoughts on this piece? to claim cash from in our Aol.com Benefiber, GSK $6.5M Class Action Settlement . TheWells Fargo GAP Insurance Settlementsfinal approval hearing is scheduled on the 15th of November 2021. I would like to be a part of this. final approval hearing is scheduled on the 15th of November 2021. Terms and Conditions. Click to share on Twitter (Opens in new window), Click to share on Facebook (Opens in new window), Click to share on LinkedIn (Opens in new window), Click to share on Reddit (Opens in new window), Click to share on Pinterest (Opens in new window), Click to share on WhatsApp (Opens in new window), Rodan + Fields Lash Boost Contains Serious Side Effects $38M Class Action Settlement, StubHub, Inc. Settles Lawsuit Alleging Violations of Consumer Protection Laws, Electrolux Dryer Class Action Settlement Reports Of Fires From Lint Buildup, Chipotle Mexican Grill, Inc. Settlement Delivery, Service Fees Misrepresented. Beyond TRID: Safeguarding compliance on every loan, Opinion: Setting the record straight on mortgage pricing, Mortgage fintech Maxwell launches SSO tool for lenders, A guide to optimizing client engagement and communication. your claim status, claim form or questions about when payments are Though many consumers reported lash growth after using this product, they also reported Read More, StubHub, Inc. has agreed to enter a settlement after being accused of violating California consumer protection laws. Digital closings continue to evolve What title companies need to know, How the FRB Pilot could impact the real estate industry. You can change these settings at any time. Public Employees Credit Union data breach class action settlement. 10% of the settlement fund will be allocated for this class. Read About More Class Action Lawsuits & Class Action Settlements: document.getElementById( "ak_js_1" ).setAttribute( "value", ( new Date() ).getTime() ); Top Class Actions is a Proud Member of the American Bar Association, Various Trademarks held by their respective owners. Your article was successfully shared with the contacts you provided. Privacy Policy | No proof is required. The self-important judge does not own my details. Andrew Mackmin, et al. Havent heard anything since they sent me confirmation and a code to hold on to. Taking this information, will will help rectify you complaint! Antitrust agreements, such as the ones described in the 2015 amended complaint, are outlawed by federal law due to the unjust burden placed on consumers and the negative impact on fair markets. Send us your story with as much detail as possible to fill out our investigation. Regulators at the. Final approval of this settlement was granted Aug. 8, 2022. A settlement has been reached resolving claims that Chipotle Mexican Read More. Florida? We had it set up to have our mortgage taken out weekly because we were told that that would save a seven year loan interest only to find out that they didnt do it but yet we have paperwork saying that they would give us that. Claim forms are due by Oct. 6, 2021. Both the company and the plaintiffs have agreed to the terms of the proposed settlement. Class members who are not current customers are former customers. I used atms from those banks and was charged$3-$4 in fees then my bank charged me $1.50 per transaction. You guys know just saying ADD ME doesnt automatically add you, right? Top Class I also got charged out rages fees for out of network ATM fees , please add me, Would like to be add. The class action lawsuit we filed alleges that Wells Fargo failed to implement and maintain the proper software and protocols to correctly determine whether a mortgage modification was required under federal regulations. - You are a merchant in the US and you contracted to get payment processing from Wells Fargo Merchant Services, and In the states identified below, state law requires indirect auto lenders such as WF Auto to ensure that a refund is issued. The contract is valid within the identified class period, from August 4, 2011, to February 8, 2021. Horn is currently involved in litigation against the CFPB which will test the agencys interpretation of another statute, and its authority to police redlining. In order to receive a settlement payment, Class Members must file a valid claim form by May 11, 2022. directory! 2006-2023 HW Media, LLC. The customer should not be account-managed within the class period. I got this clam form didnt know next steps, Rodan + Fields Lash Boost Product Grows Lashes at a Dangerous Cost! According to the lawsuit, in 2018 and 2019 Wells Fargo declined to provide information to either borrower because both accounts were in active foreclosure ligation. %%EOF Additionally, Frotman wrote that Wells Fargo has misinterpreted CFPBs amendments to Regulation X, which requires servicers to provide information requested by borrowers. For information on deleting the cookies, please consult your browsers help function. We were robbed of $1500 from eBay automotive and can get no support from eBay. Read About More Class Action Lawsuits & Class Action Settlements: document.getElementById( "ak_js_1" ).setAttribute( "value", ( new Date() ).getTime() ); My coinbase account was locked for many months. Add me I have chase bank and they charge double the fees on ATM and I have just noticed that. Markovits, Stock, & DeMarco, LLC, DannLaw, and their co-counsel recently helped their clients resolve a class action lawsuit against Wells Fargo related to glitches in the bank's loan modification program: Ryder v. Wells Fargo Bank N.A.here. Wells Fargo agreed to pay $95.7 million to more than 5,300 home mortgage consultants to resolve a pair of class-action legal claims that allege wage-and . Hacked the hackers and returned my money for a good 10% fee. Total Settlement Amount: $45,000,000 Class Representative Proposed Incentive Fee: $7,500 Law Firms: Frank Sims Stolper LLP Franklin D. Azar & Associates, PC Levin Sedran & Berman Claim Form: Wells Fargo Refund of GAP Fees Settlement Claim Form Trying to file a complaint. Wells Fargo Merchant Services, LLC will pay up to $40 million to settle a class action alleging it added excessive charges to merchants' monthly invoices.

Refus Visa Famille Accompagnante Passeport Talent, List Of Monster Reactions 5e, Walgreens Payroll Department, Satans Slaves Nz, Fun Facts About John Newlands, Articles W

wells fargo class action lawsuit 2021 claim form