Gallucci v. Boiron, Inc. Settlement Website

Gallucci v. Boiron, Inc. Settlement Claim Form

This Claim Form only relates to qualifying purchases of products manufactured by Boiron such as Oscillococcinum, Children’s Oscillococcinum, Arnicare, Quietude, Camilia or Coldcalm (a “Boiron Product”). Do not complete this Claim Form if you did not make a qualifying purchase of a Boiron Product.

You may submit only one Claim Form, and two people cannot submit Claim Forms for the same qualifying purchase of a Boiron Product.

CLAIMANT INFORMATION

All of the information below is required. If you do not provide all of the information below, your claim may be denied.

Name

First Name:	Middle:	Last Name:

Your Address

Please provide your current mailing address.

Address1
Address2
City
State
Zip
Postal Code
Province
Country

Contact Number Telephone Number:

Email Address

Email Address:

CLAIM INFORMATION

You must provide the information in the table below for each purchase of Oscillococcinum or any other Boiron product. If available, you must provide proof of each purchase you list below. If you cannot provide proof of a particular purchase, you may still submit your claim as detailed below. If you do not provide all of the information below, your claim may be denied.

QUALIFYING PURCHASES OF BOIRON PRODUCTS

Product Name:

Store Name:

Store Address:

City:

State:

Zip Code:

Date of Purchase:

	/		/

Purchase Price
$

Proof of Purchase Attached?

Yes No

PROOF OF PURCHASE

If available, proof of purchase is required for each qualifying purchase of a Boiron product listed above. There is a limit of $100.00 per household for claims containing proof(s) of purchase.

NO PROOF OF PURCHASE

If you do not have a proof of purchase, you may submit a claim for Boiron products you purchased by completing the Claim Information table above to the best of your knowledge and affixing your electronic signature to the below Certification Under Penalty of Perjury. Non-proof-of-purchase claims will be processed after claims that are submitted with a proof of purchase. Non-proof of purchase claims are eligible for a payment of $10.00 per Product, are subject to a $50.00 per household limit, and may be reduced based on the number of claims received.

CERTIFICATION UNDER PENALTY OF PERJURY

I hereby certify under penalty of perjury, as follows:

All of the information on this Claim Form is true and correct;
If I have proof of a qualifying purchase of any Boiron product that I have listed on this Claim Form, I am providing such proof with the submission of this Claim Form. If I do not have a proof of purchase for a qualifying purchase listed on this Claim Form, I certify that I purchased the product for which I submit the claim.
I understand that the Claim Administrator may contact me to verify any of the information that I have provided on this Claim Form or to verify any of the proofs of purchase that I have submitted with this Claim Form; and
I understand that the decision of the Claim Administrator is final and binding on me.

Signature

By clicking the 'Agree and Submit' button, I am affixing my electronic signature to this claim form, and agree that it shall have the same force and effect as if I had manually signed the claim form.