Dickerson, et al. v. York International Corporation, et al.

1. Estimated Date that Coil was purchased (whether purchased separately or as part of a split system or packaged residential air handler, condensing unit, or HVAC unit): *
2. Estimated Date that Coil was installed (whether purchased separately or as part of a split system or packaged residential air handler, condensing unit, or HVAC unit): *
3. What brand is/was the Copper Coil? * York Fraser-Johnston Luxaire Coleman Evcon Guardian Champion Dayton
4. Was the Copper Coil installed in a residential dwelling in the United States for your personal, family or household use? *
   Yes No
5. Was the Copper Coil installed in a light commercial building in the United State? *
   Yes No
6. If known, please provide the name of the company that installed your Copper Coil (separately or as part of a split system or packaged residential air handler, condensing unit, or HVAC unit):
   Name
   Street Address
   City
   Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon State
   Zip Code
7. Provide the address where your Copper Coil was or is installed (if different from your address provided in Part 1):
   Street Address
   City
   Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon State
   Zip Code
8. What is the Model Number of your Copper Coil or of the split system or packaged residential air handler, condensing unit, or HVAC unit containing your Copper Coil: *
9. What is the Serial Number of your Copper Coil or of the split system or packaged residential air handler, condensing unit, or HVAC unit containing your Copper Coil: *
10. 10. Please provide the following information about your preferred or closest nearby authorized JCI dealer. Click here to locate an authorized dealer near you.:
    Name
    Street Address
    City
    Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon State
    Zip Code

1. At any time between January 1, 2008 and March 15, 2017, did you experience a first failure of your Copper Coil while the Copper Coil was covered by its original limited five year warranty or extended ten year warranty, as a result of leaking or any other reason and as a result incur out-of-pocket expenses? *

   Yes No
   Identify the approximate date that the failure occurred: *

   Did the first failure result in your replacing the Copper Coil? *

   Yes No

   Please describe the failure with as much detail as possible: *
2. At any time between January 1, 2008 and March 15, 2017, did you experience a second failure of your Copper Coil while the Copper Coil was covered by its original limited five year warranty or extended ten year warranty, as a result of leaking or any other reason? *

   Yes No
   Identify the approximate date that the failure occurred: *

   Did the second failure result in your replacing the Copper Coil? *

   Yes No

   Please describe the second failure with as much detail as possible: *
3. If you experienced two or more failures of your Copper Coil prior to March 15, 2017, did the failures (either or all of them combined) cause you to pay for labor, refrigerant, or parts? *

   Yes No
   Approximately how much did you pay out-of-pocket for labor, refrigerant, or parts, associated with the first replacement of your Copper Coil(s)? * $

   Approximately how much did you pay out-of-pocket for labor, refrigerant, or parts, associated with the second replacement of your Copper Coil(s)? * $

   Approximately how much did you pay out-of-pocket for labor, refrigerant, or parts, associated with the third replacement of your Copper Coil(s)? * $

1. After March 15, 2017, did you experience a first failure of your Copper Coil while the Copper Coil was covered by its original limited five year warranty or extended ten year warranty, as a result of leaking or any other reason? *

   Yes No
   Identify the approximate date that the failure occurred: *

   Did the first failure result in your replacing the Copper Coil? *

   Yes No

   Please describe the failure with as much detail as possible: *
2. After March 15, 2017, did you experience a second failure of your Copper Coil while the Copper Coil was covered by its original limited five year warranty or extended ten year warranty, as a result of leaking or any other reason? *

   Yes No
   Identify the approximate date that the failure occurred: *

   Did the second failure result in your replacing the Copper Coil? *

   Yes No

   Please describe the second failure with as much detail as possible: *
3. If you experienced a second failure of your Copper Coil that occurred after March 15, 2017, did the failures (either or both of them) cause you to pay for labor, refrigerant, or parts? *

   Yes No
   Approximately how much did you pay out-of-pocket for labor, refrigerant, or parts, associated with the first replacement of your Copper Coil(s)? * $

   Approximately how much did you pay out-of-pocket for labor, refrigerant, or parts, associated with the second replacement of your Copper Coil(s)? * $

IN ORDER TO RECOVER UNDER THIS SETTLEMENT, YOU MUST PROVIDE THE SETTLEMENT ADMINISTRATOR WITH EVIDENCE THAT BETWEEN JANUARY 1, 2008 AND MARCH 15, 2017, YOU PURCHASED AN UNCOATED YORK, FRASER-JOHNSTON, LUXAIRE, COLEMAN, EVCON, GUARDIAN, CHAMPION, OR DAYTON BRAND COPPER EVAPORATOR COIL OR COPPER CONDENSER COIL, SEPARATELY OR AS PART OF A SPLIT SYSTEM OR PACKAGED RESIDENTIAL AIR HANDLER, CONDENSING UNIT, OR HVAC UNIT. YOU MAY DO SO BY SUBMITTING ANY COMPETENT EVIDENCE ESTABLISHING THE REQUIRED PROOF OF PURCHASE, INCLUDING, FOR EXAMPLE, AN INVOICE, RECEIPT, PHOTOGRAPH, OWNERS’ MANUAL, OR REGISTRATION CARD.

IN ORDER TO RECEIVE A $75 SERVICE REBATE CERTIFICATE, WHICH IS APPLICABLE TO AUTHORIZED CLAIMANTS WHO, AFTER MARCH 15, 2017 EXPERIENCED ONE FAILURE OF THEIR COPPER COIL, YOU MUST PROVIDE THE SETTLEMENT ADMINISTRATOR WITH EVIDENCE OF THE COPPER COIL FAILURE. YOU MAY DO SO BY SUBMITTING, FOR EXAMPLE, AN INVOICE(S), RECEIPT(S), PHOTOGRAPH(S), CORRESPONDENCE TO OR FROM JCI OR AN HVAC DEALER OR CONTRACTOR, WARRANTY CLAIM(S), OR ANY OTHER COMPETENT EVIDENCE OF THE FAILURE.

IN ORDER TO RECEIVE CASH REIMBURSEMENT FOR LABOR, REFRIGERANT, OR PARTS INCURRED IN CONNECTION WITH THE REPLACEMENTS OF TWO OR MORE COPPER COILS, YOU MUST PROVIDE THE SETTLEMENT ADMINISTRATOR WITH (A) PROOF THAT THE COPPER COILS WERE REPLACED; AND (B) EVIDENCE OF THE AMOUNTS YOU PAID OUT-OF-POCKET TO REPLACE SUCH COILS. YOU MAY DO SO BY SUBMITTING, FOR EXAMPLE, INVOICE(S), RECEIPT(S), CANCELLED CHECK(S), CREDIT CARD STATEMENTS, OR ANY OTHER COMPETENT EVIDENCE OF YOUR OUT-OF-POCKET LOSSES.

YOU MUST ATTACH COPIES OF THESE DOCUMENTS TO THIS CLAIM FORM WHEN YOU SUBMIT IT TO THE SETTLEMENT ADMINISTRATOR.

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You can also mail, email or fax your documentation, along with a print out of your confirmation page to:

Dickerson v. York International Corporation
Settlement Administrator
1650 Arch Street, Suite 2210
Philadelphia, PA 19103
FAX: (484) 350-4442
EMAIL: questions@jccoppercoilsettlement.com

I declare under penalty of perjury under the laws of the United States that I am a Class Member (as defined in the Class Notice), and that the information in this Claim Form and any documentation attached to it are true and correct to the best of my knowledge. If I did not provide required documents, it is because I do not have them.