THIS CLAIM FORM MUST BE SUBMITTED ON THE SETTLEMENT WEBSITE NO LATER THAN OCTOBER 7, 2019.
IMPORTANT: PLEASE READ THE NOTICE BEFORE COMPLETING THIS CLAIM FORM
If you have any questions about the Claim Form, the payment options, or the documentation requirements, please read the full Notice
available at www.PixelSettlement.com
Payment Election: If your claim is determined to be valid and eligible for payment, please indicate your preferred method of payment
and provide any required information.
You do not need to have experienced audio failures on your Pixel or Pixel XL in order to make a claim and be eligible for payment. Please
read the Notice for more information about payment options.
If one or more of the below boxes are already filled in, it means that we have records indicating that you meet the specified criteria. You
do not need to check in the box, but to be eligible for payment, you will need to verify that the information next to the box is correct by
completing the remaining portions of this form and submitting it.
Each Pixel purchased may be the subject of only one claim. Class members who purchased multiple Pixels may submit a separate claim
for each Pixel purchased.
SELECT ALL THAT APPLY:
I paid a deductible to Assurant on an insurance claim relating to audio failures on a first generation Pixel or Pixel XL.
Maximum file size: 5 mb
Allowed file types: .jpg, .jpeg, .tif, .tiff, .gif, .png, .pdf
Maximum number of files allowed: 10