LIFELABS DATA BREACH CLASS ACTION

CLAIM FORM

First Name*: Last Name*: Telephone Number*:

Sai Tharmavelautham 6476687245
Address*: Apartment, if any:
197Randall_cres
City*: Province / State*: Postal / Zip Code*: Country*:
Scarborough Ontario M1m3j9 Canada
Provincial Health Card Number*:

Email Address:
saikantha@gmail.com

*Required field
By checking this box, I hereby certify that I spent time or money responding to the
✔
LifeLabs Data Breach, and that I am claiming compensation from the Settlement Fund.*

I would like the payment from the Settlement Fund to be made as follows:

Payment by Interac e-transfer to the following email address: saikantha@gmail.com

Payment by e-transfer will be received more rapidly than by cheque.

OR

Payment by cheque mailed to the following mailing address.

A processing fee of $2.00 will be deducted from your payment if you request a cheque.

Address:
Apartment, if any:
City:
Province / State:
Postal / Zip Code:
Country:

If mailing this form, sign your name on the signature line below.
If submitting this form electronically, insert your signature or type your name on the signature line below.

By signing and submitting this form, I consent that my Provincial Health Card Number and other personal
information will be used for the purpose of confirming that I am an eligible class member and for the processing
of your claim. I further understand that only KPMG staff involved in the administration of the LifeLabs Privacy
Breach Class Action will have access to my personal information. Your responses will be stored securely and
retained only for as long as is required for the purposes set out above or as otherwise required to comply with
applicable law and professional standards. Any personal information collected, used or stored by KPMG Canada
as part of this process will be in accordance with KPMG Canada’s Privacy Policy.

Signature:
For assistance with submitting a claim form, please contact us at 1-833-494-0108
You may submit the claim form that is completed and signed by email to lifelabssettlement@kpmg.ca or by mail to KPMG INC., C/O
LifeLabs Claims Administrator, 600 boul. de Maisonneuve West, Suite 1500, Montréal, Québec, H3A 0A3.
© 2023 KPMG LLP, an Ontario limited liability partnership and a member firm of the KPMG global organization of independent member
firms affiliated with KPMG International Limited, a private English company limited by guarantee. All rights reserved.