In re: Checkers Data Security Breach Litigation

Case No. 8:19-cv-01386-VMC-CPT

UNITED STATES DISTRICT COURT FOR THE MIDDLE DISTRICT OF FLORIDA

Please click below to file a claim online. The deadline to a file a claim online is October 28, 2020.

OR

If you are returning to a edit a claim, enter the Claim ID and Confirmation Code as they appear in the confirmation email.

THIS CLAIM FORM MUST BE SUBMITTED BY: OCTOBER 28, 2020

CLASS MEMBER INFORMATION:

The Settlement Administrator will use this information for all communications regarding this Claim Form and the Settlement. If this information changes prior to distribution of the settlement benefits, you must notify the Settlement Administrator in writing at the address above.

* Required Fields
SETTLEMENT BENEFITS

Documented Expense Reimbursement
If you have documentation establishing that you suffered out-of-pocket losses, unreimbursed charges, or time spent remedying issues relating to the Checkers Data Breach, you can make a claim for reimbursement of up to $5,000, including up to 4 hours of documented time at $20 per hour. You must submit supporting documentation for this claim.

Attested Expense Reimbursement
If you do not have documentation, you will still be eligible to self-certify your losses and time spent remedying issues relating to the Checkers Data Breach. As compensation, you can make a claim to receive four (4) restaurant vouchers of $5.00 each, which may be redeemed at any Checkers or Rally’s restaurant, valid for one (1) year and freely transferrable.


1. Did you use a credit or debit card at an affected Checkers location during the exposure window for that particular location (click here to see a list of locations and exposure windows)?

(Proceed to Question 2)
(You are not eligible to submit a claim)

2. What is the restaurant number of the Checkers location where you made your purchase (list up to three) and the dates on which you made your purchases (list up to three)?

(click here to see a list of locations and restaurant number)

3. Do you have proof of your purchase using a credit or debit card at an affected Checkers location during the exposure window? (Examples: purchase receipt, credit card statement, bank statement)

(Skip to Question No. 5)
(Proceed to Question 4)

4. If you made a credit or debit card purchase at an affected Checkers location during the Data Breach exposure window for that location, you can make a claim to receive four (4) restaurant vouchers of $5.00, valid for one (1) year and freely transferrable. You must complete the attestation and sign the Claim Form below.

DOCUMENTED CLAIMS FOR OUT-OF-POCKET LOSSES, UNREIMBURSED CHARGES, OR TIME SPENT REMEDYING ISSUES RELATING TO THE DATA BREACH

5. Do you have documents proving you experienced out-of-pocket losses or unreimbursed charges, or that you spent time remedying issues relating to the Checkers Data Breach? If so, you may submit a claim, with supporting documentation, for up to $5,000 in out-of-pocket losses, unreimbursed charges, or time spent remedying issues related to the Checkers Data Breach.

(Proceed to the chart below)
(You are not eligible to submit a claim under this category. Please refer to Question 4 for instructions on how to submit a claim to receive four (4) restaurant vouchers of $5.00, valid for one (1) year and freely transferrable.)

If you fail to provide the required documentation to support a claim under this category (or if the documentation you provide is deemed insufficient by the Settlement Administrator), your claim will be processed under Question 4. You will not be entitled to a cash payment. However, if your claim for undocumented losses is approved, you will still receive four (4) restaurant vouchers of $5.00 each, redeemable at any Checkers or Rally’s restaurant, valid for one (1) year, and freely transferrable.

Loss Type
(Check all that Apply)
Date of Loss
(MM/DD/YYYY)
Amount of Loss Description of Loss Description of Supporting Documentation
(Identify what you are attaching and why)

DOCUMENTATION

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    ATTESTATION AND SIGNATURE

    I do hereby swear (or affirm), under penalty of perjury, that the information provided above is true and accurate to the best of my knowledge and that the compensation I am claiming is based on losses I reasonably believe to the best of my knowledge were the result of the Checkers Data Breach.

    Your Claim Form has been submitted successfully.

    HOWEVER, it appears one or more of the documents you uploaded were not successfully received. Please see below for which file(s) had errors and log back in to your existing Claim online to re-upload your document(s). Alternatively, you can send your documents with your Submitted Claim ID to the Settlement Administrator by email to: Info@CheckersDataBreachSettlement.com.

    Please print this page for your records.

    Your Claim Details

    Submitted Claim ID:
    Confirmation Code:
    You will need the above Submitted Claim ID and Confirmation Code if you would like to edit your Claim at a later time, so please print this page for your records.
    CLAIM INFORMATION
    First Name
    Last Name
    Street Address
    Street Address 2
    City
    State
    Zip Code
    Email Address
    Telephone Number
    Signature
    Date

    If you have any questions regarding your Claim, please provide the Submitted Claim ID listed above and email us at Info@CheckersDataBreachSettlement.com