Children's Hospital Payment Election Form - Strategic Claims Services

Children’s Hospital ERISA Settlement Payment Election Form

Please provide your information

If you are or may be a Current Participant or Former Participant who participated in the Plan during the period from January 18, 2016 through May 12, 2025 (the “Class Period”), or are or may be the Beneficiary or Alternate Payee of a such participants, you may be entitled to payment of a portion of the Net Settlement Amount. The amount paid to each Current Participant, Former Participant, Beneficiary or Alternate Payee will be determined by a Plan of Allocation subject to Court approval.

You do not need to take any action in order to receive payment under the Settlement. However, if you wish to update your address or beneficiary information, or to elect a rollover of Settlement funds to another qualified retirement account, please do so below.

Payments made to Current Participants, or to Beneficiaries or Alternate Payees of a Participant who have an Active Account in the Plan shall be made into these persons’ individual investment accounts in the Plan.

Payments made to Former Participants, or to Beneficiaries or Alternate Payees of Former Participants who do not have an Active Account in the Plan will be made by check or, if elected below, rollover into another qualified retirement account. “Former Participant” means a member of the Settlement Class who does not have an Active Account (i.e., a balance greater than $0) as of the date on which the Court authorized notice to the Class.

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Email(Required)

Last 4 Digits of SSN(Required)

Mail ID Number

This number can be found on the mailer you received. It will be above your name and 5 digits long.

I am a(Required)

Current or Former Participant

Beneficiary

Alternate Payee

Participant Name(Required)

First Last

Beneficiary Information Upload(Required)

Please provide any documents that indicate that you are the beneficiary of the decedent’s retirement account.

Drop files here or

Accepted file types: pdf, jpg, png, tif, Max. file size: 32 MB.

Payment Election

Choosing the non-rollover option entails the Settlement Administrator withholding 20% or more of your total payment for tax withholdings. The Settlement Administrator will mail your check to the Name and Address listed above.

NOTE Choosing the rollover option: There is no promise or assurance that these funds are eligible for rollover or tax-preferred treatment.

The decision to seek rollover treatment is yours alone. Any questions about taxation or rollover treatment must be directed to your tax advisor or accountant. No one associated with this case can provide you with assistance or advice of any kind in this regard or answer any tax questions.

Payment Election

I would like a check mailed to my current address.

I would like you to rollover my payment to an eligible account (details provided below)

Rollover Account Information

Rollover Institution(Required)

Rollover Account Name(Required)

Rollover Account Number

Address to mail the rollover check(Required)

Street Address Address Line 2 City State ZIP Code

QDRO Certification

Required Certification Regarding Qualified Domestic Relations Order (“QDRO”): I hereby certify and represent under penalty of perjury that no portion of the payment to be received hereunder is subject to a QDRO, or, that a true, accurate, and current copy of any applicable QDRO is attached hereto along with the name and address of any payee other than the Class Member. Payment will be made in accordance with any QDRO supplied.

QDRO Certification(Required)

I hereby certify and represent under penalty of perjury that no portion of the payment to be received hereunder is subject to a QDRO.

I hereby certify that a true, accurate, and current copy of any applicable QDRO is attached hereto along with the name and address of any payee other than the Class Member. Payment will be made in accordance with any QDRO supplied.

QDRO File Upload(Required)

Accepted file types: png, pdf, tif, jpg, Max. file size: 32 MB.

Unique ID