SETTLEMENT REGISTRATION/CLAIM FORM Auto Airbag Settlement for Certain Pontiac Vehicles

Transcription

1 Certain ontiac Vehicles A SETTLEMENT FUND HAS BEEN CREATED, AND YOU MAY BE ENTITLED TO A CASH AYMENT. To Register/Submit a Claim for a ayment from the Settlement Fund (a Settlement ayment ), YOU MUST: 1. Bring or have brought your vehicle (one of the Subject Vehicles listed in Section II, below) to a GM-ontiac dealership for the Takata Airbag Recall Remedy, as directed by a recall notice; OR 2. Have sold or returned your Subject Vehicle after April 11, 2013 and prior to June 9, 2017, if your Subject Vehicle was recalled prior to June 9, AND YOU MUST EITHER: 1. Register and submit your claim for reimbursement of the reasonable expenses you incurred related to the Takata Airbag Recall; OR 2. Register to potentially receive up to a maximum of 500 from the Settlement Fund. IMORTANT NOTE: Some vehicles included in the Settlement will be recalled at a later date and others may not require a recall. Your receipt of a Settlement tice does not mean your vehicle is subject to a recall. lease refer to GM-ontiac s website, My.GM.com/Recalls, or the National Highway Traffic Safety Administration s website, for the latest information about Takata recalls and to determine if your vehicle is subject to a recall. 01-CA9674 S7081 v age 1 of 7

2 Certain ontiac Vehicles INSTRUCTIONS FOR REGISTERING/SUBMITTING A CLAIM FOR A SETTLEMENT AYMENT lease Read These Instructions Carefully 1. Subject to certain limited exclusions, you are a person or entity eligible to register/submit a claim for a Settlement ayment if: a. You owned or leased, on June 9, 2017, a Subject Vehicle distributed for sale or lease in the United States or its territories or possessions, AND you bring or have brought your Subject Vehicle to a GM-ontiac dealership for the Takata Airbag Recall Remedy; or, b. You sold, or returned pursuant to a lease, a Subject Vehicle distributed for sale or lease in the United States or its territories or possessions after April 11, 2013 and before June 9, 2017, if the Subject Vehicle was recalled prior to June 9, To register/submit a claim for a Settlement ayment, you must either: a. Submit an electronic Registration/Claim Form online by visiting (online registration will result in expedited processing); or, b. Submit a paper Registration/Claim Form by completing this form and returning it along with any required documentation by U.S. Mail or to: Mailing Address: Auto Airbag Settlement Settlement tice Administrator.O. Box 3207 ortland, OR info@autoairbagsettlement.com 3. The deadline for submitting a Registration/Claim Form is as follows: a. If you sold or returned, pursuant to a lease, a recalled Subject Vehicle after April 11, 2013 and before June 9, 2017, and your vehicle was recalled under the Takata Airbag Inflator Recall prior to June 9, 2017, you have one year from the date that the Settlement becomes final (the Effective Date ) to submit a Registration/Claim Form. b. If you owned or leased a Subject Vehicle on June 9, 2017, the deadline for submitting a Registration/Claim Form is one year after the Effective Date, or one year after the date the Recall Remedy is performed on your Subject Vehicle, whichever is later, until the Final Registration/Claim Deadline is reached. IMORTANT: NO REGISTRATION/CLAIM FORMS MAY BE SUBMITTED AFTER THE FINAL REGISTRATION/CLAIM DEADLINE. THE EFFECTIVE DATE AND THE FINAL REGISTRATION/CLAIM DEADLINE ARE NOT YET KNOWN, BUT WILL BE OSTED ROMINENTLY ON THE SETTLEMENT WEBSITE, WHEN THEY ARE KNOWN. 4. If you are or were the registered owner or lessee of more than one Subject Vehicle, you must submit a separate Registration/Claim Form for each Subject Vehicle to obtain a separate out-of-pocket Settlement ayment for each Subject Vehicle you own(ed) or lease(d). However, claims for unreimbursed expenses cannot be duplicative. 02-CA9674 S7082 v age 2 of 7

3 Certain ontiac Vehicles 5. Capitalized terms in this Form have the same meaning as provided in the Settlement Agreement, which is available for download at The Long Form tice, which is also available for download at or by calling , also explains key terms of the Settlement, including the definition of Effective Date. 6. Type or print legibly in blue or black ink. Do not use any highlighters. rovide all requested information to complete and submit this Form, attach supporting documentation, as specified below, and sign the Form. IMORTANT: KEE A COY OF YOUR COMLETED REGISTRATION/CLAIM FORM AND THE SUORTING DOCUMENTS. ANY DOCUMENTS YOU SUBMIT WITH YOUR FORM WILL NOT BE RETURNED. IF YOUR CLAIM IS REJECTED FOR ANY REASON, YOU WILL BE NOTIFIED AND GIVEN AN OORTUNITY TO ADDRESS ANY DEFICIENCIES. THE SETTLEMENT SECIAL ADMINISTRATOR S DECISIONS REGARDING CLAIMS FOR REIMBURSEMENT OF OUT-OF-OCKET EXENSES SUBMITTED BY CLASS MEMBERS IS FINAL AND CANNOT BE AEALED. SECTION I: CLASS MEMBER INFORMATION lease fill in the below contact information. This information will only be used to contact you regarding the Auto Airbag Settlement. Business Organization/Trust Name(s) (if applicable): First Name: MI: Last Name: Address 1: Address 2: City: State: ZI: Country: hone: 03-CA9674 S7083 v age 3 of 7

4 Certain ontiac Vehicles SECTION II: VEHICLE INFORMATION lease enter the Vehicle Identification Number (VIN) of your Subject Vehicle. The VIN can be found on the dashboard of the vehicle, the vehicle s registration, or the vehicle s title, and is 17 characters long. To confirm whether or not your vehicle is eligible for participation in the Auto Airbag Settlement, please visit Vehicle Identification Number (VIN): GM-ONTIAC (TOYOTA SETTLEMENT) SUBJECT VEHICLES Check the box next to your vehicle model and model year. Check only one. ontiac Vibe Did you purchase or lease your Subject Vehicle before June 9, 2017? 2. Did you still own or lease your Subject Vehicle on June 9, 2017? 3. Did you bring your Subject Vehicle to a GM-ontiac dealership for the Takata Airbag Recall Remedy? 4. If you answered to Question 2 in this Section, did you sell, or return pursuant to a lease, your Subject Vehicle after April 11, 2013 and before June 9, 2017? 04-CA9674 S7084 v age 4 of 7

5 Certain ontiac Vehicles SECTION III: OUT-OF-OCKET EXENSES 1. Did you pay for any expenses, as further defined below, related to the Takata Airbag Inflator Recall for your Subject Vehicle that have not been reimbursed by GM-ontiac? If you answered to Question 1 in this Section, please complete the remainder of this Section and Section IV to submit a claim for reimbursement of the out-of-pocket expenses you incurred, in addition to a potential later payment of up to 250 from the Settlement Fund. If you answered to Question 1 in this Section, please skip to and complete Section IV below to register for total potential payments of up to 500 from the Settlement Fund. The Settlement Special Administrator will process and approve payments from the Settlement Fund in accordance with the terms of the Settlement Agreement. ayments for reimbursable out-of-pocket expenses will be made first, and if sufficient funds remain in the Settlement Fund at the end of each program year, that money will be paid to Class Members who: (a) submitted claims for out-of-pocket expenses in that year or prior program years that were previously rejected; or (b) sought to register for a Residual Distribution payment only. Reimbursements for out-of-pocket expenses will be made on a first-in-first-out basis during years one through three, until the Settlement Fund is depleted for that year. If there are no more funds to reimburse Class Members in years one through three, those Class Members will be moved to subsequent years for reimbursement. If approved reimbursements to Class Members in year four and until the Final Registration/Claim Deadline exceed the amount available in the Settlement Fund, reimbursements will be made on a pro rata basis. Settlement ayments (excluding reimbursements for out-of-pocket expenses) are capped at 250 per Class Member in the program year in which the Class Member registers for a payment from the Residual Distribution (or a subsequent year if the Class Member is moved to the subsequent year due to insufficient funds in years one through three). Approved payments to Class Members to reimburse them for reasonable out-of-pocket expenses are not capped, unless pro rata reimbursements are required in year four. After the Final Registration/Claim Deadline, if sufficient funds remain in the Settlement Fund and it is administratively feasible, the remaining funds will be paid to all Class Members who registered/submitted a claim for a Settlement ayment on a per capita basis, up to a maximum of 250 per Class Member. If there are additional funds remaining after paying all registered Class Members a maximum of 250 per Class Member, and if it is administratively feasible, the remaining funds will be distributed per capita to all Class Members. lease periodically check the Settlement website, for updates regarding the Settlement, including information about the deadlines for filing Registration/Claim Forms. 05-CA9674 S7085 v age 5 of 7

6 Certain ontiac Vehicles 2. lease identify the reasonable out-of-pocket expenses you incurred relating to the Takata Airbag Inflator Recall for your Subject Vehicle that have not been reimbursed by GM-ontiac. The categories below are potentially eligible for reimbursement, but you may include other reasonable expenses you incurred related to the Takata Airbag Inflator Recall for your Subject Vehicle. lease fill in as many expenses as apply. Rental car and transportation expenses after requesting and while awaiting the Recall Remedy from a GM-ontiac Dealer: Towing charges to a GM-ontiac Dealer for completion of the Recall Remedy: Childcare expenses necessary during the performance of the Recall Remedy by a GM-ontiac Dealer: Costs associated with repairing driver or passenger front airbags containing Takata phase-stabilized ammonium-nitrate (SAN) inflators: Lost wages resulting from lost time from work to drop off to, and pick up from, the GM-ontiac Dealer for performance of Recall Remedy: Storage fees incurred after requesting and while awaiting Recall Remedy: Other: If Other, please describe here: IMORTANT: IF YOU NEED MORE SACE, LEASE SUBMIT A SEARATE AGE WITH ADDITIONAL INFORMATION. 3. If you have any invoices, receipts, or other documents that support the expenses identified in response to Question 2 above, including a written explanation of the necessity of the expenses you incurred, please submit them. If you have such documents supporting your expense, you may be required to submit them. At the discretion of the Settlement Special Administrator, reimbursement for certain reasonable out-of-pocket expenses may be made to Class Members even in the absence of any supporting documentation, and the Settlement Special Administrator may approve and pay for other reimbursable claims that the Settlement Special Administrator deems to be reasonable out-of-pocket expenses. 06-CA9674 S7086 v age 6 of 7

7 Certain ontiac Vehicles SECTION IV: ATTESTATION I affirm, under penalty of perjury and under the laws of the United States of America, that the information in this Registration/Claim Form is true and correct to the best of my knowledge, information, and belief, and that I am the sole and exclusive owner of all claims being released by the Settlement. I understand that my Registration/Claim Form may be subject to audit, verification, and review by the Settlement Special Administrator and Court. I also understand that, if my Registration/Claim Form is found to be fraudulent, I will not receive any payment from the Settlement Fund. Signature: Date: MM DD YY GM-ontiac, the Settlement Special Administrator, and/or the Settlement tice Administrator are not responsible for any documents that are misdelivered, lost, illegible, damaged, destroyed, or otherwise not received by U.S. Mail, , or other delivery method. 07-CA9674 S7087 v age 7 of 7