Claim Form – Fastrich v. Continental General Insurance Company Lawsuit April 22, 2019 Claim Forms Fastrich v. Continental General Insurance Company Claim Form Step 1 of 5 - Claim Form Instructions 0% In order for you to qualify to receive a payment related to Fastrich v. Continental General Insurance Company as described in the Notice of this Settlement (the “Class Notice”), you must file a Claim Form either in paper or electronically on the Settlement Website, www.strategicclaims.net. Your claim will be considered only if you comply with all of the following conditions: You must be a person to whom a Class Notice was addressed, and you must be listed as a potential Class Member on the Fastrich v. Continental General Insurance Company Class List. If you have a question about whether you are listed as a potential Class Member, please contact the Settlement Administrator at (866) 274- 4004, or call Class Counsel at (515) 223-4567. You must have sold insurance policies for Continental General Insurance Company, Great American Financial Resources, Inc., American Financial Group, Inc., and/or Cigna Supplemental Benefits through Loyal American Life Insurance Company and/or American Retirement Life Insurance Company (collectively, the “Defendants”). You must accurately complete all required portions of the Claim Form. You must sign this Claim Form, which includes the Certification. If you file a Claim Form electronically, you may electronically sign the form with a “click through” electronic signature which shall have the same force and effect as if you signed the form on paper. By signing and submitting the Claim Form, you are certifying that you are a member of the Settlement Class in the Fastrich v. Continental General Insurance Company case. You have two options to complete a Claim Form: (1) MAIL the completed and signed Claim Form and Certification by First-Class U.S. Mail, postage prepaid, postmarked no later than June 6, 2019, to: Fastrich v. Continental General Insurance Company Lawsuit c/o Strategic Claims Services P.O. Box 230 Media, PA 19063 Or (2) you may complete and submit the Claim Form and Certification using the Settlement Administrator’s Settlement Website. When you successfully complete the online Claim Form, you will receive a receipt that your claim has been submitted. If you do not complete and submit the Claim Form postmarked or filed online by June 6, 2019, you cannot receive any payment from the Settlement. So that you will have a record of the date of your mailing of the Claim Form and its receipt by the Settlement Administrator, you are advised to use (but are not required to use) either the Settlement Website or U.S. Mail by Certified Mail, Return Receipt Requested. CLAIMANT INFORMATIONThe Claims Administrator will use the contact information for all correspondence relevant to this claim, including the distribution (check), if the claim is ultimately determined to be eligible for payment. If the contact information changes, then you must notify the Claims Administrator in writing.Claimant's Name*(as you would like it to appear on your check if eligible for payment)Additional NameAddress* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Last 4 Digits of Social Security Number (for individuals) or T.I.N. (for estates, trusts, corporations, etc.)Best Phone Number*Alternate Phone NumberEmail* Enter Email Confirm Email SECTION AYOU MUST CERTIFY YOUR ELIGIBILITY FOR PAYMENT BY CHECKING ONE OR MORE OF THE FOLLOWING BOXES:* I sold long-term care insurance policies for any of the Defendants written before January 2000 and still in force at any time between October 25, 2011 and the Effective Date of the Settlement Agreement (after final approval of the settlement and the Judgment has become Final). I was entitled to, but did not receive, commissions in accordance with the vesting provisions of any agreement with any of the Defendants at any time from October 25, 2011 through the Effective Date of the Settlement Agreement. I sold insurance policies for Defendants and became an agent of record for said policies, but subsequently, at any time from October 25, 2011 through the Effective Date of the Settlement Agreement, Defendants replaced me as agent of record on, and stopped paying me commissions for, said policies. For each policy, please indicate below: Number of policies sold (check one box):*I sold between 1-5 policies, or I sold more than 5 policies but no longer have records to prove each sale;I sold more than 5 policies and have records to prove each sale. For each of the policies sold for which you have records, please indicate below:Policies Sold*I sold more than 5 policies and have records to prove each sale. For each of the policies sold for which you have records, please indicate below:Name of the policy holderDate of policy issuancePolicy number Policies Sold Where I was Replace as Agent of Record*I sold insurance policies for Defendants and became an agent of record for said policies, but subsequently, at any time from October 25, 2011 through the Effective Date of the Settlement Agreement, Defendants replaced me as agent of record on, and stopped paying me commissions for, said policies. For each policy, please indicate below:Name of the policy holderDate of policy issuanceDate of change of agentPolicy number Please attach any supporting documents you wish to provide. Please note that when the file upload completes the file name will be listed below the upload box. You can click the red x to remove the file if it was added in error.Documentation Drop files here or Please attach your proof in PDF format if possible. If you have a large number of files, please consider uploading a ZIP file. The total maximum file size limit is 32MB. SECTION BYOU MUST CERTIFY YOUR ELIGIBILITY FOR PAYMENT BY CHECKING THE FOLLOWING BOX. IF YOU ARE NOT ABLE TO MAKE THE STATEMENT BELOW, YOU ARE NOT ELIGIBLE FOR PAYMENT.* I am not an employee, executive officer, partner, director or controlling person, or legal representative, heir, successor, or assign, of any of Defendants or any subsidiary or affiliates of Defendants or entity in which any of Defendants have a controlling interest. I certify under penalty of perjury that the foregoing information supplied is true and correct to the best of my knowledge.Signature of Claimant*Please type your name, this will be considered your electronic signatureDate* FormID CommentsThis field is for validation purposes and should be left unchanged.