Weeks v. Google LLC (Pixel)

Claim Form

THIS CLAIM FORM MUST BE SUBMITTED ON THE SETTLEMENT WEBSITE NO LATER THAN OCTOBER 7, 2019.

CLAIMANT INFORMATION

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 INFORMATION

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.

Select one:





PAYMENT OPTION

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.

Details Concerning Purchase and Failures:

SELECT ALL THAT APPLY:

Insurance Deductible Paid Relating to the Audio Defect:

I paid a deductible to Assurant on an insurance claim relating to audio failures on a first generation Pixel or Pixel XL.

UPLOAD SUPPORTING DOCUMENTATION

Maximum file size: 5 mb

Allowed file types: .jpg, .jpeg, .tif, .tiff, .gif, .png, .pdf

Maximum number of files allowed: 10

VERIFICATION