Automobile Insurance Claim Form by lmd11395


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									Van Horn v Nationwide
Claims Administrator
PO Box 6809
Portland, OR 97228-6809


     v.4                                  01-CA6254
                                                          CLAIM FORM


              You are receiving this claim form because Nationwide records indicate a vehicle you owned was declared a total loss as the result
of an accident or theft during the time period October 2, 1993 to February 10, 2009, and you made a claim for rental vehicle benefits with your
Nationwide insurer. Your claim may be part of the litigation and proposed settlement described in the Notice that was sent along with this form.

              If you are determined to be a Class Member and you return a valid claim form, you may be entitled to a settlement payment. If
you wish to be considered for a payment under this settlement, you must complete, sign, and date this Claim Form, and mail it to the address
listed below with a post-mark no later than Thursday, January 28, 2010. If you do not submit a timely valid claim form, you will receive
no payment from the settlement.

              Please answer the following questions under oath to the best of your knowledge. You must answer, to the best of your ability,
all these questions in order to be eligible to recover. Except as noted below, failure to respond to any question may preclude you from
receiving a settlement payment.

               Please do not call or write to the Court, Nationwide or Nationwide’s counsel with questions about completing this Claim Form.
You can obtain information and documents regarding the settlement and this lawsuit by visiting the website
or calling 1-866-329-9963 for the Claims Administrator. You may also call or write to one of the Class Counsel.

                            Please Type or Print in the Boxes Below; Do NOT use Red Ink, Pencil, or Staples

PART 1: Contact Information

 Last Name                                                               First Name

 Street Address

 City                                                                                                       State         Zip Code

 Phone Number
              -                -

       PART 2: Questions Regarding Eligibility To Participate In Settlement

1. At any time between October 2, 1993 and February 10, 2009, did you have a vehicle insured with a Nationwide company listed below?

       Yes              No
                                                         Nationwide Companies
     1. Nationwide Property and Casualty Insurance Company                      9. Nationwide Insurance Company Of America

     2. Nationwide Mutual Fire Insurance Company                                10. Nationwide Mutual Insurance Company

     3. Colonial County Mutual Insurance Company                                11. Nationwide Affinity Insurance Company of America

     4. Nationwide Assurance Company                                            12. Nationwide General Insurance Company

     5. Titan Indemnity Company                                                 13. Titan Insurance Company

     6. Victoria Automobile Insurance Company                                   14. Victoria Fire and Casualty Company

     7. Victoria National Insurance Company                                     15. Victoria Select Insurance Company

     8. Victoria Specialty Insurance Company

2. At any time between October 2, 1993 and February 10, 2009, did a Nationwide company declare your vehicle to be a "total loss" as a
result of an accident or theft?
       Yes              No
3. If you answered "Yes" to Question No. 2, identify the Nationwide company through whom you insured the vehicle subject to a total loss
during the time period of October 2, 1993 to February 10, 2009:

4. To the best of your recollection, please provide the approximate date of the accident/theft:             -
                                                                                                     (MM)           (YYYY)

5. Did you receive coverage for your rental vehicle from your Nationwide insurer?            Yes              No

6. Did you return your rental vehicle before Nationwide communicated to you the date on which your car rental vehicle benefits would
       Yes              No
7. Before agreeing to a settlement offer for the total loss of your vehicle, did you receive a communication from your Nationwide insurer that
offered a settlement, and set a date for termination of car rental benefits that was sooner than the number of days of rental vehicle coverage
described in your policy; and that was not conditioned on reaching a settlement before the termination of rental vehicle benefits?

       Yes              No
8. With the exception of this lawsuit, have you ever filed or participated in any lawsuit (either as a plaintiff or as a member of a class) relating
to the accident or theft of your vehicle, and in which you challenged the amount of rental benefits you received under your automobile policy
with your Nationwide insurer?

       Yes              No

9. If you answered “Yes,” to Question No. 8, did the settlement of that lawsuit include a release of rental vehicle benefits and/or other claims
against your Nationwide insurer?
       Yes              No

 10. To the extent the information is available to you, please provide the following information with respect to the total loss incident. It is
 understood that many class members may not have this information readily available, and the failure to provide this information will
 not affect your entitlement to be paid.
 (a) the policy number for your insurance policy:

            I cannot find the policy number.               The policy number is:

 (b) the endorsement number which provided for rental vehicle benefits:

            I cannot find the endorsement number.          The endorsement number is:

PART 3: Release
As part of this settlement, and as explained in more detail in the Notice accompanying this Claim Form, class members are releasing the
following companies:

            Nationwide Property And Casualty Insurance Company, Nationwide Insurance Company Of America, Nationwide Mutual Fire
            Insurance Company, and Nationwide Mutual Insurance Company, Colonial County Mutual Insurance Company, Nationwide
            Affinity Insurance Company of America, Nationwide Assurance Company, Nationwide General Insurance Company, Titan
            Indemnity Company, Titan Insurance Company, Victoria Automobile Insurance Company, Victoria Fire and Casualty Company,
            Victoria National Insurance Company, Victoria Select Insurance Company, and Victoria Specialty Insurance Company

from any and all liability for the following claims:

            Any and all claims, causes of action, demands, rights or liabilities for damages, in contract, in tort, under any statute or regulation,
            and/or derived directly or indirectly from any statute, or claims under federal, state, local or other laws, including, but not limited
            to claims for extra-contractual damages, exemplary (punitive) damages, policy or premium proceeds, consequential losses or
            damages, interest, equitable relief, declaratory relief, injunctive relief (however described or defined), known or unknown, fixed or
            contingent, that the Named Plaintiffs, the Class Members and/or the Settlement Class Members now have asserted, could have
            asserted, or may in the future assert and referring or relating in any way to rental car reimbursement coverage or benefits provided,
            denied or available to Class Members and Settlement Class Members during the Class Period under any Nationwide insurance
            policy or endorsement. The Released Claims include, but are not limited to:

            (a) the release of all matters alleged in the Second Amended Complaint, including but not limited to the actions pleaded therein,
            and to be pleaded therein in the contemplated amendment to the Second Amended Complaint; and

            (b) the release and waiver of any and all rights under the California Civil Code section 1542 (and any and all provisions, rights, and
            benefits conferred by any law of any state or territory of the United States or principle of common law that is similar, comparable,
            or equivalent to section 1542 of the California Civil Code), which reads as follows: “A GENERAL RELEASE DOES NOT

PART 4: Sign And Date Your Claim Form
Pursuant to 28 U.S.C. § 1746, I certify under penalty of perjury that I have read this Claim Form and all of the information on this Claim
Form is true and correct to the best of my knowledge.

Print Name _____________________________________________________

Signature                                                                                    Date          -          -
                                                                                                    (MM)       (DD)          (YYYY)

PART 5: Mail Your Claim Form
                                           Claim forms must be postmarked by January 28, 2010 and mailed to:
                                                                  Van Horn v Nationwide
                                                                  Claims Administrator
                                                                  PO Box 6809
                                                                  Portland, OR 97228-6809


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