James Roy et al. v. Titeflex Corporation et al.

384003V (Md. Cir. Ct. 2013)


GASTITE® AND WARDFLEX® YELLOW CSST CLASS ACTION SETTLEMENT CLAIM FORM


* Required

I. DESCRIPTION OF PROPERTY AND INSTALLATION OF CSST


Single Family Residence
Condominium
Apartment Building
Duplex
Commercial
Other/ Describe



YES
NO








YES
NO



II. CLAIMANT INFORMATION













YES
NO

III. IDENTIFICATION OF CSST

For definitions of any of the bold capitalized terms referred to below, please refer to the Settlement Agreement.


Gastite®
Wardflex®
Other

IV. INSPECTION

If your claim is approved, you will be contacted by the Claims Administrator to schedule an inspection of your CSST system.


V. REPAIRS & OTHER RELIEF

If, at the time of inspection, the Inspector determines that your CSST is not installed in compliance with current gas and electrical codes in the State of Maryland, the Inspector will provide you with a quote for the cost of a Code Compliant Repair. The quoted price will be discounted by the Settlement Subsidy amount for which you qualify, which will range from $125 and $0.

You may also qualify to receive a Payment Voucher that may be used to defray the cost of a Lightning Protection System. To be eligible for this Payment Voucher, the Property must be located in an area of Flash Density 4 or greater based on the VAISALA lightning density map that the Claims Administrator uses and qualify under NFPA 780 factors for a Lightning Protection System. For a Property containing a Structure of 3,000 sq. feet or less, the value of the Payment Voucher shall be $200. For a Property containing a Structure of more than 3,000 sq. feet, the value of the Payment Voucher shall be $400.


VI. SUPPORTING DOCUMENTATION

Please click below to submit documentation supporting your claim as described. Failure to provide any of the documents requested below may result in a denial of your Claim.

Proof of Ownership: Enclose a document showing that you are the current owner of the property on which the subject CSST was installed. While there may be other acceptable documents, some of the most common examples include copies of your property deed, most recent property tax bill, or most recent mortgage statement.

Photographs: Photographs may be uploaded or submitted by mail. If submitted by mail, all photographs should be at least 3 inches by 5 inches and have the property address or claim number written clearly on the back.

NOTE: Color photographs are better able to depict your CSST, and therefore more likely to meet the requirements set forth below:

At least three (3) photographs that capture the yellow CSST, taken from three different vantage points; and at least three (3) photographs that capture the name of the manufacturer or brand name of your CSST and the date of manufacture, printed in black lettering on the yellow CSST.

Please note that all items submitted for the evaluation of this claim become the property of Titeflex and Ward, and cannot be returned to you regardless of the disposition of this claim.

If you need to repair or replace your CSST before your claim is resolved, you MUST provide Titeflex and Ward with reasonable notice. If you have already repaired or replaced your CSST without notifying Titeflex or Ward about this claim or before Titeflex or Ward has completed its evaluation, your claim may be denied.

I would like to submit my documentation by mail.
I would like to submit my documentation online.


VII. CERTIFICATION

This claim is signed under penalties of perjury. Per my signature below, I authorize the Claims Administrator, Titeflex Corp., and Ward Manufacturing, LLC to verify the Claim, including by retaining an Inspector to inspect the CSST materials on the Property, if Titeflex Corp., and Ward Manufacturing, LLC determines an inspection is necessary. I certify that the information provided above is true and correct to the best of my knowledge and that any documents submitted have not been edited to misrepresent any of the information reflected in them. I further certify that all photographs and videos that I have supplied (or will supply) are from the CSST that is the subject of this claim.



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