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Honda Settlement Registration/Claim Form

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Honda Settlement Registration/Claim Form SETTLEMENT REGISTRATION/CLAIM FORM Auto Airbag Settlement for Certain Honda and Acura Vehicles A SETTLEMENT FUND HAS BEEN CREATED, AND YOU MAY BE ENTITLED TO A CASH PAYMENT. To Register/Submit a Claim for a Payment from the Settlement Fund (a “Settlement Payment”), YOU MUST: 1. Bring or have brought your vehicle (one of the “Subject Vehicles” listed in Section II, below) to a Honda or Acura dealership for the Takata Airbag Recall Remedy, as directed by a recall notice; OR 2. Have sold or returned your Subject Vehicle after November 11, 2008 and before September 19, 2017, if your Subject Vehicle was recalled before September 19, 2017. AND YOU MUST EITHER: 1. Register and submit your claim for reimbursement of the reasonable expenses you incurred related to the Takata Airbag Recall; OR 2. Register to potentially receive up to $500 from the Settlement Fund. IMPORTANT NOTE: Some vehicles included in the Settlement may be recalled later and others may not require a recall. Your receipt of a Settlement Notice does not necessarily mean your vehicle is subject to a recall. Please refer to the Honda and Acura website, www.HondaAirbagInfo.com, or the National Highway Traffic Safety Administration’s website, www.SaferCar.gov, for the latest information about Takata recalls and to determine if your vehicle is subject to a recall. H 01- CA9674 T2491 v.03 11.06.2017 Page 1 of 8 SETTLEMENT REGISTRATION/CLAIM FORM Auto Airbag Settlement for Certain Honda and Acura Vehicles INSTRUCTIONS FOR REGISTERING/SUBMITTING A CLAIM FOR A SETTLEMENT PAYMENT Please Read These Instructions Carefully 1. Subject to certain limited exclusions, you are eligible to register/submit a claim for a Settlement Payment if: a. You owned or leased, on September 19, 2017, a Subject Vehicle distributed for sale or lease in the United States or its territories or possessions, AND you bring or you have brought your Subject Vehicle to a Honda or Acura dealership for the Takata Airbag Recall Remedy; or b. You sold, or returned pursuant to a lease, a Subject Vehicle distributed for sale or lease in the United States or its territories or possessions after November 11, 2008 and before September 19, 2017, if the Subject Vehicle was recalled prior to September 19, 2017. 2. To register/submit a claim for a Settlement Payment, you must either: a. Submit an electronic Registration/Claim Form online by visiting www.AutoAirbagSettlement.com (online registration will result in expedited processing); or b. Submit a paper Registration/Claim Form by completing this form and returning it along with any required documentation by U.S. Mail or email to: Mailing Address: Auto Airbag Settlement Settlement Notice Administrator P.O. Box 3207 Portland, OR 97208-3207 Email: [email protected] 3. The deadline for submitting a Registration/Claim Form is as follows: a. If you sold or returned, pursuant to a lease, a recalled Subject Vehicle after November 11, 2008 and before September 19, 2017, and your vehicle was recalled under the Takata Airbag Inflator Recall prior to September 19, 2017, you have one year from the date that the Settlement becomes final (the “Effective Date”) to submit a Registration/Claim Form. b. If you owned or leased a Subject Vehicle on September 19, 2017, the deadline for submitting a Registration/Claim Form is one year after the Effective Date, or one year after the date the Recall Remedy is performed on your Subject Vehicle, whichever is later, until the Final Registration/Claim Deadline is reached. IMPORTANT: NO REGISTRATION/CLAIM FORMS MAY BE SUBMITTED AFTER THE FINAL REGISTRATION/CLAIM DEADLINE. THE EFFECTIVE DATE AND THE FINAL REGISTRATION/CLAIM DEADLINE ARE NOT YET KNOWN, BUT WILL BE POSTED PROMINENTLY ON THE SETTLEMENT WEBSITE, WWW.AUTOAIRBAGSETTLEMENT.COM, WHEN THEY ARE KNOWN. 4. If you are or were the registered owner or lessee of more than one Subject Vehicle, you must submit a separate Registration/Claim Form for each Subject Vehicle to obtain a separate out-of-pocket Settlement Payment for each Subject Vehicle you own(ed) or lease(d). However, claims for unreimbursed expenses cannot be duplicative. H 02- CA9674 T2492 v.03 11.06.2017 Page 2 of 8 SETTLEMENT REGISTRATION/CLAIM FORM Auto Airbag Settlement for Certain Honda and Acura Vehicles 5. Capitalized terms in this Form have the same meaning as provided in the Settlement Agreement, which is available for download at www.AutoAirbagSettlement.com. The Long Form Notice, which is also available for download at www.AutoAirbagSettlement.com or by calling 1-888-735-5596, also explains key terms of the Settlement. 6. Type or print legibly in blue or black ink. Do not use highlighters. Provide all requested information, attach any supporting documentation, and sign the Form. IMPORTANT: KEEP A COPY OF YOUR COMPLETED REGISTRATION/CLAIM FORM AND THE SUPPORTING DOCUMENTS. ANY DOCUMENTS YOU SUBMIT WITH YOUR FORM WILL NOT BE RETURNED. IF YOUR CLAIM IS REJECTED FOR ANY REASON, YOU WILL BE NOTIFIED AND GIVEN AN OPPORTUNITY TO ADDRESS ANY DEFICIENCIES. THE SETTLEMENT SPECIAL ADMINISTRATOR’S DECISIONS REGARDING CLAIMS FOR REIMBURSEMENT OF OUT-OF-POCKET EXPENSES SUBMITTED BY CLASS MEMBERS ARE FINAL AND CANNOT BE APPEALED. SECTION I: CLASS MEMBER INFORMATION Please fill in the below contact information. This information will only be used to contact you regarding the Auto Airbag Settlement and safety recalls. Business Organization/Trust Name(s) (if applicable): First Name: MI: Last Name: Address 1: Address 2: City: State: ZIP: Country: Phone: – – Email: H 03- CA9674 T2493 v.03 11.06.2017 Page 3 of 8 SETTLEMENT REGISTRATION/CLAIM FORM Auto Airbag Settlement for Certain Honda and Acura Vehicles SECTION II: VEHICLE INFORMATION Please enter the Vehicle Identification Number (VIN) of your Subject Vehicle. The VIN can be found on the dashboard of the vehicle, the vehicle’s registration, or the vehicle’s title, and is 17 characters long. To confirm whether or not your vehicle is eligible for participation in the Auto Airbag Settlement, please visit www.AutoAirbagSettlement.com. Vehicle Identification Number (VIN): HONDA SETTLEMENT SUBJECT VEHICLES Check the box next to your vehicle model and model year. Check only one. Honda Civic 4D Honda Civic 2D 2001 2002 2003 2004 2001 2002 2003 2004 2005 2006 2007 2008 2005 2006 2007 2008 2009 2010 2011 2012 2009 2010 2011 2012 2013 2014 2015 2013 2014 2015 Honda Accord 4D-L4 Honda Accord 4D-V6 2001 2002 2003 2004 2001 2002 2008 2009 2005 2006 2007 2008 2010 2011 2012 2013 2009 2010 2011 2012 2013 Honda Accord 2D-L4 Honda Accord 2D-V6 2001 2002 2008 2009 2001 2002 2008 2009 2010 2011 2012 2013 2010 2011 2012 2013 Honda Accord Plug-In Hybrid Honda CR-V 2014 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Honda Accord Crosstour 2010 2011 2012 2013 2014 2015 H 04-CA9674 T2494 v.03 11.06.2017 Page 4 of 8 SETTLEMENT REGISTRATION/CLAIM FORM Auto Airbag Settlement for Certain Honda and Acura Vehicles Honda Pilot Honda Odyssey 2003 2004 2005 2006 2002 2003 2004 2007 2008 2009 2010 2011 2012 2013 2014 2015 Honda Ridgeline Honda Element 2006 2007 2008 2009 2003 2004 2005 2006 2010 2011 2012 2013 2007 2008 2009 2010 2014 2011 Honda Fit Honda Insight 2007 2008 2009 2010 2010 2011 2012 2013 2011 2012 2013 2014 2014 Honda CR-Z Acura CL 2011 2012 2013 2014 2003 2015 Acura TSX Acura TSX WGN 2009 2010 2011 2012 2011 2012 2013 2014 2013 2014 Acura ILX Acura MD-X 2013 2014 2015 2016 2003 2004 2005 2006 Acura RDX Acura TL/TLX 2007 2008 2009 2010 2002 2003 2009 2010 2011 2012 2013 2014 2011 2012 2013 2014 2015 2016 2017 Acura RL/RL-X Acura ZD-X 2005 2006 2007 2008 2010 2011 2012 2013 2009 2010 2011 2012 2014 2015 2016 2017 Acura FCX 2010 2011 2012 2013 2014 H 05 - CA9674 T2495 v.03 11.06.2017 Page 5 of 8 Yes 1. Did you purchase or lease your Subject Vehicle before September 19, 2017? No Yes 2. Did you still own or lease your Subject Vehicle on September 19, 2017? No 3. Did you bring your Subject Vehicle to a Honda or Acura dealership for the Takata Airbag Recall Yes Remedy? No 4. If you answered “No” to Question 2 in this Section, did you sell, or return pursuant to a lease, your Yes Subject Vehicle after November 11, 2008 and before September 19, 2017? No SECTION III: OUT-OF-POCKET EXPENSES 1. Did you pay for any expenses, as further defined below, related to the Takata Airbag Inflator Recall Yes for your Subject Vehicle that have not been reimbursed by Honda? No If you answered “Yes” to Question 1 in this Section, please complete the remainder of this Section and Section IV to submit a claim for reimbursement of the out-of-pocket expenses you incurred, in addition to two potential payments of up to $500 from the Settlement Fund. If you answered “No” to Question 1 in this Section, please skip to and complete Section IV below to register for two potential payments of up to $500 total from the Settlement Fund. The Settlement Special Administrator will process and approve payments from the Settlement Fund. Payments for reimbursable out-of-pocket expenses will be made first, and if enough money remains in the Settlement Fund at the end of each program year, that money will be paid to Class Members who: (a) submitted claims for out-of-pocket expenses in that year or prior years that were previously rejected; or (b) sought to register for a Residual Distribution payment only.
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