O'Sullivan v. AMN Services, Inc.

Filing 76

ORDER by Judge Joseph C. Spero granting 63 Motion for Settlement (Attachments: # 1 Exhibit 1, # 2 Exhibit 2, # 3 Exhibit 3) (jcslc1, COURT STAFF) (Filed on 9/10/2013)

Exhibit 3

CLAIM FORM
O’SULLIVAN, ET AL. V. AMN SERVICES, LLC, ET AL.
U.S. DISTRICT COURT, NORTHERN DISTRICT OF CALIFORNIA
CASE NO. 12-CV-2125-JCS
YOUR INDIVIDUAL WORKWEEKS: <<individual workweeks>>
YOUR ESTIMATED MINIMUM PRETAX SETTLEMENT PAYMENT: <<estimated
award>>
YOU MUST TIMELY COMPLETE, SIGN AND RETURN THIS FORM BY [+45 DAYS FROM
MAILING] TO BE ELIGIBLE FOR A MONETARY RECOVERY.
<<Name>>
<<Address Line 1>>
<<Address Line 2>>
<<City, State>>
<<Telephone Number>>

____________________________________
____________________________________
____________________________________
____________________________________
____________________________________

If your name or address is different from those shown above, print the corrections on the lines to the
right. If you move, please send us your new address.

YOU MUST COMPLETE, SIGN AND MAIL THIS FORM BY FIRST CLASS U.S. MAIL OR
EQUIVALENT, POSTAGE PAID, POSTMARKED ON OR BEFORE [+45 DAYS FROM
MAILING] ADDRESSED AS FOLLOWS TO BE ELIGIBLE TO RECEIVE A RECOVERY.
INSERT CLAIMS ADMINISTRATOR INFORMATION
As stated above, you qualify to claim an estimated minimum pretax payment of approximately
$<<estimated award>>
This amount is based on your employment with AMN Services, LLC (“AMN”) as a non-exempt
healthcare professional in the State of California during the period from January 30, 2008 through
[insert date of preliminary approval] (the “Class Period”).
.
This estimated amount is based on AMN’s records, which indicate that you worked <<individual
workweeks>> workweeks while employed by AMN as a non-exempt healthcare professional during the
Class Period. If you disagree with the number of workweeks listed, you may dispute the number of
workweeks by submitting satisfactory documentation to the Claims Administrator with this Claim Form
showing that you worked a different number of workweeks during the Class Period. The Claims
Administrator will then make a determination on your dispute based on your employment records and
any other documents you submit. In resolving a dispute, AMN’s records shall be presumed to be
accurate and correct unless the information you submit proves otherwise.
CERTIFICATION AND RELEASE OF CLAIMS
By signing this Claim Form and in exchange for the payment described above, I agree to release AMN
and any parent, subsidiary, affiliate, predecessor or successor, and all agents, employees, officers,
directors, attorneys, and healthcare facility clients, including but not limited to Kaiser Permanente, Inc.,
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thereof for all “Class Released Claims,” defined as: any and all claims, debts, liabilities, demands,
obligations, guarantees, costs, expenses, attorney’s fees, damages, or causes of action, contingent or
accrued, which relate to wage and hour and California Labor Code or Federal Wage and Hour claims
arising from the factual allegations specified in the October 5, 2012, Amended Consolidated Class
Action Complaint for the O’Sullivan/Ogues Action and in the May 1, 2013 Complaint for the Bell
Action, including but not limited to waiting time penalties, meal periods, rest breaks, timely payment of
wages, minimum and overtime wages or rates, wage statements, reimbursements, unlawful deductions
from wages, and derivative or related claims, including but not limited to Private Attorney General Act
claims, claims for restitution and other equitable relief, liquidated damages, punitive damages, or
penalties of any nature whatsoever, and any other claims or legal theories asserted, or which could have
been asserted under the California Labor Code § 2699 or Business & Professions Code (including
Section 17200), the California Wage Orders or California Labor Code or Fair Labor Standards Act.

Date:_____________________________

Signature:_______________________________

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