PROPERTY DAMAGE CLAIM FORM - Classaction.ca
PROPERTY DAMAGE CLAIM FORM - Classaction.ca PROPERTY DAMAGE CLAIM FORM - Classaction.ca
- 4 -If the contact person is other than the Class Member, please provide identification of person signingthis Property Damage Claim Form (check one only):I am an authorized employee, officer or director of the above-identified ClassMember. I am signing this Property Damage Claim Form to register the ClassMember for settlement benefits.I am the trustee, receiver or other representative of the above-identified ClassMember. I am signing this Property Damage Claim Form to register the ClassMember for settlement benefits. Please attach a copy of the court order or otherofficial document appointing you as trustee, receiver or representative and stateyour name, title, mailing address and telephone number in the space below.____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
- 5 -Section 3. Points SystemClass Members will receive a pro-rata share of the monies in the Property Damage Fundbased on their approved points total. Points are awarded based on the following criteria.Please check each box as applicable.The Class Member’s property (for greater clarity, property refers to “real property” (i.e. feesimple)) (the "Property") has not had an indoor TCE Reading above 20 µg/m 3 The Property has had one or more indoor TCE reading(s) above 20 µg/m 3 but not above 200µg/m 3 The Property has had one or more indoor TCE reading(s) above 200 µg/m 3Soil Vapour Extraction (“SVE”), Sub-Slab Extraction, and/or Sub-Slab Depressurization unitinstalled on the PropertyThe Property is dependent on an SVE unit (but the unit not installed on the Property)Heat Recovery Ventilator and/or Photo-Catalytic Oxidation unit installed on the PropertySealants/passive barriers installed on the PropertyOne or more testing wells installed on the PropertyClass Member was required to evacuate from his or her Property while remediation wasperformed on his or her Property for:3 – 14 nights15 – 60 nights61 – 120 nightsmore than 120 nightsThere were more than two members in the household during the time in which the ClassMember was required to evacuate from his or her Property while remediation was performed onhis or her PropertyIf after submitting your Property Damage Claim Form, but before disbursement of the PropertyDamage Fund, your status under the point system has changed (e.g., you have a higher TCEreading or a qualifying unit installed on the property), you can submit an amended PropertyDamage Claim Form to the Claims Administrator asking that the point value of your claim berecalculated.
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- Page 3: - 3 -Section 2. Identification of C
- 4 -If the contact person is other than the Class Member, please provide identifi<strong>ca</strong>tion of person signingthis Property Damage Claim Form (check one only):I am an authorized employee, officer or director of the above-identified ClassMember. I am signing this Property Damage Claim Form to register the ClassMember for settlement benefits.I am the trustee, receiver or other representative of the above-identified ClassMember. I am signing this Property Damage Claim Form to register the ClassMember for settlement benefits. Please attach a copy of the court order or otherofficial document appointing you as trustee, receiver or representative and stateyour name, title, mailing address and telephone number in the space below.____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
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