Fill - Free fillable BZT Settlement Benets may be available for PDF form

BZTPCW1

*BZTFIRST*

EZ-Flo Settlement Claims Administrator

P.O. Box 404041

Louisville, KY 40233-4041

BZT

Houze, et al. v. BrassCraft Manufacturing

Company, et al., Case No. BC493276

Superior Court of the State of California –

County of Los Angeles

EZ-Flo Yellow Brass Settlement Claim Form

FOR CLAIMS

PROCESSING

ONLY

OB CB

DOC

REV

RED

Settlement Benets may be available for

Eligible Conditions in Covered Products

by submitting this Claim Form to the

EZ-Flo Claims Administrator.

YOU MUST SIGN AND DATE THIS CLAIM FORM ON PAGE 4 TO BEGIN THE CLAIM HANDLING PROCESS.

1) Claimant Information

Name of Property Owner

Address of Property Owner (Street)

City State Zip Code

LIST ALL PROPERTY OWNERS. If there are additional owners, attach a list with each additional owner’s name and address.

If you are making a claim for a business or entity, provide the following:

Name of business or entity

Name of person submitting claim on behalf of business or entity

Position or Title

Address of Property Owner (Street)

City State Zip Code

QUESTIONS? CALL 1-866-798-2031 OR VISIT WWW.EZ-FLOSETTLEMENT.COM Page 1 of 4

Primary Address

Primary Address Continued

City State Zip Code

CHANGE OF ADDRESS (ONLY IF DIFFERENT FROM ABOVE)

Are you (or the business or entity identied above) the current owner of the property? Yes No

If NO, what dates did you (or the business or entity) own the property:

Start Date End Date

2) Claimant Contact Information/Mailing Address

Street

City State Zip Code

— — — —

Home Phone Number Work Phone Number

3) Address of Affected Property (“Property Unit”) (if different than mailing address)

You must submit separate Claim Forms for each property if you are seeking Settlement Benets for more

than one Property Unit. A P.O. Box is not an appropriate address; you must list the physical street address.

Street

City State Zip Code

Unit type (select one): Residential Commercial

See Section 3 of the Notice or go to www.EZ-Flosettlement.com to determine what type of Property Unit you have.

4) Identication of Covered Product(s).

YOU MUST SUBMIT PHOTOGRAPHS OF EACH COVERED PRODUCT, TAKEN WITHIN

TEN (10) YEARS OF THE DATE OF MANUFACTURE, WITH THIS CLAIM FORM.

Identify the type and number of Covered Product(s) for which you are submitting this Claim Form:

Product Type Quantity

Supply Stop

Water Connector

Fitting

Don’t Know Type / Other (please identify):

5) Proof of Date of Manufacture (Required for each Covered Product).

Product Type Date Code(s), Date(s) of Manufacture, or Date of Purchase

Supply Stop

Water Connector

Fitting

Don’t Know Type / Other (please identify):

The photographs you submit with this Claim Form must show both: (1) EZ-Flo manufacture stamp if

this stamp appears on the Covered Product; AND (2) Date of Manufacture stamp if this stamp appears

on the Covered Product. For help locating the (1) EZ-Flo Covered Product brand manufacture stamp and

(2) Date of Manufacture stamp on supply stops and water connectors, go to www.EZ-Flosettlement.com.

QUESTIONS? CALL 1-866-798-2031 OR VISIT WWW.EZ-FLOSETTLEMENT.COM Page 2 of 4

*BZTSECOND*

6) Proof of Eligible Conditions in a Covered Product(s)

To determine if you have Exterior Meringue Deposits, an Occlusion, an Inoperable Valve handle, or a Leak,

see Section 7 of the Notice or go to www.EZ-Flosettlement.com.

Are you making a claim for an Exterior Meringue Deposit? Yes No

To submit a valid claim for Exterior Meringue Deposits, the photographs you submit with this Claim Form must

show the claimed Exterior Meringue Deposits while in service. This benet is limited to 15 replacement parts per

property unit.

B. Are you making a claim for an Occlusion? Yes No

To submit a valid claim for an Occlusion, the photographs you submit with this Claim Form must show the

Covered Product in service. You must also complete and sign Afdavit “A” at the end of this Claim Form.

This benet is limited to 3 replacement parts per property unit.

C. Are you making a claim for an an Inoperable Valve handle? Yes No

To submit a valid claim for an Inoperable Valve handle, the photographs you submit with this Claim Form must

show the Covered Product in service and Exterior Meringue Deposits. You must also complete and sign Afdavit

“A” at the end of this Claim Form. This benet is limited to 3 replacement parts per property unit.

D. Are you making a claim for a Leak? Yes No

To submit a valid claim for a Leak, you must submit the Covered Product(s) to the Claims Administrator, in

accordance with the following instructions, to conrm an Eligible Condition:

Upon receipt of your completed and signed Claim Form and photographs of the Covered Product(s), and after a

Leak Claim involving a Covered Product is conrmed, the Claims Administrator will provide you with a return

shipping authorization and pre-paid shipping label for return of the Covered Product(s) to EZ-Flo. Upon receipt

of the return shipping authorization and pre-paid shipping label, you have sixty (60) days to return the Covered

Product(s) to EZ-Flo or the Claims Administrator may deny your Leak Claim.

E. Are you making a claim for $3,500 or less in Property Damage resulting from a Leak? Yes No

The maximum Settlement Benet for Property Damage Claims is $3,500 per Property Unit. Under this settlement,

you may not recover for property damage covered and paid by insurers. You may recover for deductibles not paid

by insurance. If you are making more than one claim for property damage, you must submit a separate Claim

Form for each claim.

Date of Leak/property damage loss (mm/dd/yyyy):

Total Leak amount claimed:

Leak only without property damage claimed $ ~Or~ Leak with property damage claimed $

Have you reported, or do you intend to report, your claim for property damage to an insurance company? Yes No

If YES, provide the name, address, phone number, claim representative of the insurance company, and claim number:

For a valid property damage claim, you must submit:

• The Covered Product to the Claims Administrator by following the procedure set forth in Section D

(claim for a Leak) above.

• Photographs depicting all alleged property damage.

• Copies of invoices, expense records, receipts, or other veriable documents for your reasonable out-of-pocket

expenses for repair or replacement of damaged property that were not otherwise paid or reimbursed by an

insurance company or other entity.

You may attach Documents or other materials in support of your property damage claim to this Claim Form (i.e., invoices, photographs,

repair estimates).

QUESTIONS? CALL 1-866-798-2031 OR VISIT WWW.EZ-FLOSETTLEMENT.COM Page 3 of 4

*BZTTHIRD*

F. Did you experience more than $3,500 in Property Damage resulting from a Leak? Yes No

If YES, choose one of the following:

I elect to limit my claim to $3,500 in Property Damage.

I elect to waive the benets of this settlement and pursue my own individual claim with my own counsel in a separate lawsuit.

The settlement gives Class Members with more than $3,500 in Property Damage the option to either (1) make a

claim for a maximum payment of $3,500 per Property Unit, regardless of the amount of actual damages claimed;

or (2) opt out of the settlement during the claims period and le an individual lawsuit against EZ-Flo, forfeiting

all Settlement Benets.

7) Prior Adjudication of Claims

Have you or someone on your behalf (e.g., insurance company or contractor) previously settled

with, released, or otherwise had claims related to this Property Unit adjudicated on the merits

against EZ-Flo that are substantially similar to those alleged in this action?

Yes No

8) Signature Verication

IMPORTANT DEADLINES: Claims for Exterior Meringue Deposits must be made within one year of the date the

Settlement Agreement becomes nal (the “Effective Date”). Claims for Occlusions and Inoperable Valves must be

made within three years of the Effective Date. Claims for Leaks that occur before the Effective Date must be made

within three years of the Effective Date or within seven years of the Date of Manufacture, whichever date is later.

Claims for Leaks that occur after the Effective Date must be made within one year of the Leak. The Effective Date

shall be posted to the settlement website www.EZ-Flosettlement.com within 10 days of the date the Final Order and

Judgment entered pursuant to the Settlement Agreement becomes nal.

I DECLARE UNDER PENALTY OF PERJURY THAT THE ABOVE INFORMATION IS TRUE. I AGREE

TO RETAIN AND TO ALLOW AN EXAMINATION OF MY RECORDS AND COVERED PRODUCTS TO

VERIFY THIS INFORMATION IF REQUIRED BY THE SETTLEMENT. I FURTHER ACKNOWLEDGE

THAT ANY COVERED PRODUCTS SUBMITTED TO THE CLAIMS ADMINISTRATOR SHALL BECOME

THE PROPERTY OF EZ-FLO INTERNATIONAL, INC. AND MAY BE DISPOSED OF WITHOUT NOTICE

AFTER THE FINAL DETERMINATION OF MY CLAIM, INCLUDING THE DETERMINATION OF ANY

APPEALS TO THE SPECIAL MASTER THEREON. IF MY CLAIM IS DENIED BECAUSE THE PART

IS NOT A COVERED PRODUCT, I WILL BE GIVEN NOTICE OF SUCH DETERMINATION AND AN

OPPORTUNITY TO RETRIEVE THE PART AT MY EXPENSE.

ALL OWNERS OF THE SUBJECT PROPERTY MUST SIGN THIS

CLAIM FORM TO BEGIN THE CLAIM HANDLING PROCESS.

Owner Signature: Date (mm/dd/yyyy): / /

Co-Owner Signature: Date (mm/dd/yyyy): / /

Business or Entity Signature: Date (mm/dd/yyyy): / /

Please make a copy of the completed form for your records.

Mail or Deliver to: EZ-Flo Settlement Claims Administrator, P.O. Box 404041, Louisville, KY 40233-4041

AFFIDAVIT OF CLAIMANT “A”

(To be completed and signed by property owner seeking Settlement Benets for a

Covered Product with an alleged Occlusion and/or an alleged Inoperable Valve)

I hereby declare under the penalty of perjury that (check all that apply):

I am making a claim for a Covered Product with an Occlusion. I hereby state that the Covered Product for

which I seek Settlement Benets has an Occlusion as dened in Paragraph 1.13.c of the Settlement Agreement.

I am making a claim for an Inoperable Valve handle that is a Covered Product. I hereby state that the Covered

Product for which I seek Settlement Benets is a stop valve that is mechanically inoperable as dened in

Paragraph 1.13.d of the Settlement Agreement.

Owner Signature: Date (mm/dd/yyyy): / /

QUESTIONS? CALL 1-866-798-2031 OR VISIT WWW.EZ-FLOSETTLEMENT.COM Page 4 of 4

*BZTFOURTH*

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