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Get a Claim Form

If you are an eligible Claimant or Provider, you can submit a claim form to ask for a cash payment from the settlement fund. Claim forms are due by April 5, 2015. Click the links below to view and print a Claimant or Provider claim form:

Claimant Claim Form – For eligible people who, between June 25, 2004 and October 31, 2014, suffered injuries that were covered by a Personal Injury Protection (PIP) or Medical Payments (MedPay) coverage provided by a personal automobile policy issued by one of the “Liberty” insurers and in one of the “Settlement States” listed on the Claimant Claim Form, and received from Liberty a total payment that was less than the amount billed for that treatment because Liberty determined that the billed charge exceeded the usual, customary, or reasonable allowance.

Provider Claim Form - For eligible people who, between June 25, 2004 and October 31, 2014, provided medical treatment to an eligible Claimant; sought payment under the PIP or MedPay coverage provided by a personal automobile policy issued by one of the “Liberty” insurers and in one of the “Settlement States” listed on the Provider Claim Form, and received from Liberty a total payment that was less than the amount billed for that treatment because Liberty determined that the billed charge exceeded the usual, customary, or reasonable allowance.

Main

Claimant/Provider Notice

Policy Holder Notice

Detailed Notice

Settlement Agreement

Preliminary Approval Order

Order Modifying the Class Schedule

If you have questions call the Settlement Administrator at 1-866-591-7240.

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Disclaimer

Please do not contact either Liberty Mutual or the Court about this Settlement. If you have questions, please refer to the Commonly Asked Questions and the other information posted here.  This site is not operated by Liberty Mutual. This Settlement is supervised by the Court and is administered by a claims administration firm that handles all aspects of claims processing. Liberty Mutual is not authorized to respond to questions from members of the Class regarding this Settlement.

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