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.
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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.
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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:
Country: Phone: –
–
Email:
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ZIP:
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. 2001 2005 2009 2013 2001 2005 2009 2013 2001 2010 2014
2010 2014
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Honda Civic 4D 2002 2003 2006 2007 2010 2011 2014 2015
2004 2008 2012
2001 2005 2009 2013
Honda Civic 2D 2002 2003 2006 2007 2010 2011 2014 2015
Honda Accord 4D-L4 2002 2003 2006 2007 2010 2011
2004 2008 2012
2001 2010
Honda Accord 4D-V6 2002 2008 2011 2012
2009 2013
Honda Accord 2D-L4 2002 2008 2011 2012
2009 2013
2001 2010
Honda Accord 2D-V6 2002 2008 2011 2012
2009 2013
2002 2006 2010 2014
Honda CR-V 2003 2004 2007 2008 2011 2012 2015 2016
Honda Accord Plug-In Hybrid
Honda Accord Crosstour 2011 2012 2015
2004 2008 2012
2013
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2005 2009 2013
SETTLEMENT REGISTRATION/CLAIM FORM Auto Airbag Settlement for Certain Honda and Acura Vehicles
Honda Pilot 2003 2004 2005 2007 2008 2009 2011 2012 2013 2015 2006 2010 2014 2007 2011 2011 2015
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Honda Odyssey 2003 2004
2009 2013
2003 2007 2011
Honda Fit 2008 2009 2012 2013
2010 2014
2010 2014
Honda CR-Z 2012 2013
2014
2003
Honda Element 2004 2005 2008 2009
2006 2010
Honda Insight 2011 2012
2013
Acura CL
Acura TSX 2010 2011 2014
2013
Acura ILX 2014 2015
2007 2011 2015
Acura RDX 2008 2009 2012 2013 2016 2017
2005 2009 2014
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2002
Honda Ridgeline 2007 2008 2011 2012
2009 2013
2010 2014
2006 2010 2014
2011
Acura TSX WGN 2012 2013
2014
2003
Acura MD-X 2004 2005
2006
2010 2014
2002 2011
Acura TL/TLX 2003 2009 2012 2013
2010 2014
Acura RL/RL-X 2006 2007 2010 2011 2015 2016
2008 2012 2017
2010
Acura ZD-X 2011 2012
2013
Acura FCX 2011 2012
2013
2012
2016
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1. Did you purchase or lease your Subject Vehicle before September 19, 2017?
Yes No
2. Did you still own or lease your Subject Vehicle on September 19, 2017?
Yes No
3. Did you bring your Subject Vehicle to a Honda or Acura dealership for the Takata Airbag Recall Remedy?
Yes No
4. If you answered “No” to Question 2 in this Section, did you sell, or return pursuant to a lease, your Subject Vehicle after November 11, 2008 and before September 19, 2017?
Yes 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 for your Subject Vehicle that have not been reimbursed by Honda?
Yes 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. Reimbursements for out-of-pocket expenses will be made on a first-in-first-out basis during years one through three, until the Settlement Fund is depleted for that year. If there is no more money to reimburse Class Members in years one through three, those Class Members will be moved to subsequent years for reimbursement. If approved reimbursements to Class Members in year four and until the Final Registration/Claim Deadline exceed the amount available in the Settlement Fund, reimbursements will be made on a pro rata basis. Settlement Payments (excluding reimbursements for out-of-pocket expenses) are capped at $250 per Class Member in the program year in which the Class Member registers for a payment (or a subsequent year if the Class Member is moved to the subsequent year due to insufficient funds in years one through three). Approved payments to Class Members to reimburse them for reasonable out-of-pocket expenses are not capped, unless pro rata reimbursements are required in year four. After the Final Registration/Claim Deadline, if enough money remains in the Settlement Fund and it is administratively feasible, the remaining money will be paid to all Class Members who registered/submitted a claim for a Settlement Payment on a per capita basis, up to a maximum of $250 per Class Member. If there are additional funds remaining after those payments and, if it is administratively feasible, the remaining money will be distributed per capita to all Class Members. Please periodically check the Settlement website, www.AutoAirbagSettlement.com, for updates about the Settlement, including information about the deadlines for filing Registration/Claim Forms.
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SETTLEMENT REGISTRATION/CLAIM FORM Auto Airbag Settlement for Certain Honda and Acura Vehicles
2. Please identify the reasonable out-of-pocket expenses you incurred relating to the Takata Airbag Inflator Recall for your Subject Vehicle that have not been reimbursed by Honda. The categories below are potentially eligible for reimbursement, but you may include other reasonable expenses. Please fill in as many expenses as apply. Rental car and transportation expenses after requesting and while awaiting the Recall Remedy from a Honda or Acura Dealer: $
●
Towing charges to a Honda or Acura Dealer for completion of the Recall Remedy: $
●
Childcare expenses necessary during the performance of the Recall Remedy by a Honda or Acura Dealer: $
●
Costs associated with repairing driver or passenger front airbags containing Takata phase-stabilized ammonium-nitrate (PSAN) inflators: $
●
Lost wages resulting from time from work to drop off to, and pick up from, the Honda or Acura Dealer for performance of Recall Remedy: $
●
Storage fees incurred after requesting and while awaiting Recall Remedy: $
●
Other: $
●
If “Other,” please describe here:
IMPORTANT: IF YOU NEED MORE SPACE, PLEASE SUBMIT A SEPARATE PAGE WITH ADDITIONAL INFORMATION. 3. If you have any invoices, receipts, or other documents that support the expenses identified in response to Question 2 above, including a written explanation of the necessity of the expenses you incurred, please submit them. If you have documents supporting your expense, you may be required to submit them. At the discretion of the Settlement Special Administrator, reimbursement for reasonable out-of-pocket expenses may be made to Class Members even without supporting documentation, and the Settlement Special Administrator may approve other claims if they are reasonable out-of-pocket expenses.
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SETTLEMENT REGISTRATION/CLAIM FORM Auto Airbag Settlement for Certain Honda and Acura Vehicles
SECTION IV: ATTESTATION I affirm, under penalty of perjury and under the laws of the United States of America, that the information in this Registration/Claim Form is true and correct to the best of my knowledge, information, and belief, and that I am the sole and exclusive owner of all claims being released by the Settlement. I understand that my Registration/Claim Form may be subject to audit, verification, and review by the Settlement Special Administrator and Court. I also understand that, if my Registration/Claim Form is found to be fraudulent, I will not receive any payment from the Settlement Fund. Signature:
Date: – MM
– DD
YY
American Honda Motor Co., Inc. (and its parent, affiliates, and related entities), the Settlement Special Administrator, and/or the Settlement Notice Administrator are not responsible for any documents that are misdelivered, lost, illegible, damaged, destroyed, or otherwise not received by U.S. Mail, email, or other delivery method. H
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