Cahill vs Keurig Green Mountain - Submit a Claim Page 1

Submit a Claim - Page 1

Contact Information:

The Settlement Administrator will use this information for all communications regarding this Claim Form and the Settlement. If this information changes prior to the distribution of payments, you must notify the Settlement Administrator. If your Claim Form is approved, Settlement Class Member Benefits will be sent to you using the information you provide here.

Please Note: The contact information provided below will be used only for communication regarding your Claim Form. Please keep a valid email and mailing address on file with the Settlement Administrator so that we can reach out regarding the status of your claim.

First Name:*

Middle Initial:

Last Name:*

Country:*

Address Line 1:*

Address Line 2:

Address Line 3:

Address Line 4:

Address Line 5:

City:*

State:*

Province:*

ZIP Code:*

Postal Code:*

Phone Number:

Email Address:*