Must be Postmarked or Emailed No Later Than May 29, 2015 OTW Ohio Tow Class Settlement c/o GCG P.O. Box 10104 Dublin, OH 43017-3104 *P-OTW%WB-POC/1* Claim Number: Control Number: CLAIM FORM If you were charged administrative fees by Camcar, Inc. (“Camcar”) or Shamrock Towing, Inc. (“Shamrock”) for towing from a private tow-away zone, between September 1, 2008 and July 17, 2014, resulting in towing charges greater than a total of $90 for towing and $12 per day for storage of a vehicle with a gross vehicle weight rating of ten thousand pounds or less, then, you may be eligible for a payment in this settlement. Please print (or type) clearly in blue or black ink. This signed Claim Form must be mailed and postmarked or emailed by May 29, 2015. Remember to include all supporting documentation that you have available. If you have more than one claim, please submit a separate Claim Form for each claim. If you have any questions, please visit www.ohiotowclasssettlement.com. 1. CLASS MEMBER INFORMATION Name (first, middle, last): Street Address: City: Email Address: Zip Code: (Email address is not required, but if you provide it you authorize the Claims Administrator to use it in providing you with information relevant to this claim.) Daytime Telephone Number: - State: - Evening Telephone Number: - - To view GCG’s Privacy Notice, please visit http://www.gcginc.com/privacy *P-OTW%WB-POC/2* 2 2. VEHICLE AND TOWING INFORMATION Camcar Shamrock Was your car towed by: Please provide the approximate date that your car was towed, and approximate address (or business location) from where your car was towed: / / This settlement applies only to the towing of vehicles with a gross weight rating of 10,000 pounds or less, which includes nearly all non-commercial vehicles. Did your vehicle have a gross weight rating of 10,000 pounds or less? Yes No If you are unsure of whether the towed vehicle had a gross weight rating of 10,000 pounds or less, please provide the make, model, and year of the vehicle below: Vehicle: Make: Model: Year: 3. DOCUMENTATION You should attach any documents that you have showing: • That your car was towed by Camcar or Shamrock between September 1, 2008 and July 17, 2014; and • The fees you were charged for towing and daily storage of your vehicle; 4. SIGN AND DATE YOUR CLAIM FORM IF YOU DO NOT HAVE RECEIPTS OR OTHER RECORDS TO SUBMIT WITH YOUR CLAIM, IT MUST BE NOTARIZED OR YOUR CLAIM WILL BE DENIED. I certify under penalty of perjury that I have read this Claim Form; I believe I am eligible for Class membership; and all of the information on this Claim Form is true and correct to the best of my knowledge. Signed: Dated: / / Print: Notary___________________________________ My commission expires: _______________________________ 5. MAIL YOUR CLAIM FORM In order to be considered for participation in the settlement, Claim Forms must be postmarked by May 29, 2015 and mailed to: Ohio Tow Class Settlement c/o GCG P.O. Box 10104 Dublin, OH 43017-3104 Instead of mailing your Claim Form, you may scan your signed form and email it to: [email protected] Please be patient. You will receive a letter telling you if you qualify for a payment. The letter will explain the process and deadlines to resolve any disagreement you may have with this determination.
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