Claim Form Mail In

Use this Claim Form to claim refunds of a portion of the purchase price of one or more of the Pods (up to a maximum of $50.00 with proof of purchase or $7.00 if you do not have proof of purchase information) and Brewers (up to a maximum of $25.00 with proof of purchase). This Claim Form is only for claims concerning the purchase(s) of Pods and/or Brewers made in Canada from June 8, 2016 until the date of the Settlement Approval Order. You may submit only one Claim Form per household or business. A “household” consists of any and all persons related by blood or marriage (whether common law or otherwise) that are cohabitating in the same dwelling unit or physical address. A “business” means any group of entities, including individuals, carrying out a commercial activity under the common beneficial ownership, control, or direction of one or more entities. All Claim Forms must be submitted online by 11:59 P.M. Eastern Time 180 Days after the Effective Date. Instructions on how to submit your proof of purchase shall be provided after submitting this claim form.


Claim Form Mail In
First Name:
Last Name:
Email (payment will be sent by e-transfer to this email):
Confirm Email:
Address:
City:
Province:
Country:
Postal Code:
Telephone Mobile for SMS verification:
Payment For Pods:
If you DO NOT have proof of purchase (in the form of receipts, email order confirmations, or shipping confirmations) for your purchase of Pods in Canada from June 8, 2016 until the date of the Settlement Approval Order, OR if you DO NOT have proof of purchase for more than 140 Pods, please check the box below.

Eligible for up to $7.00 in cash per household or business WITHOUT proof of purchase. The actual amount may vary depending upon the number of claims received by the Claims Administrator.
If you have proof of purchase (in the form of receipts, email order confirmations, or shipping confirmations) for your purchase of MORE THAN 140 Pods in Canada from June 8, 2016 until the date of the Settlement Approval Order, please check the box below, identify the applicable purchases as noted below.

Eligible for up to $0.05 per Pod shown to have been purchased on your proof of purchase, up to a maximum of $50.00 in cash per household. The actual amount will vary depending upon the number of Pods shown to have been purchased and the number of claims received by the Claims Administrator. After submission, you will get a confirmation by email asking you to submit your proof by email.
Purchases of Pods:
Product(s):
Number of pods:
Purchase date(s):
Payment For Brewers:
If you have proof of purchase (in the form of receipts, email order confirmations, or shipping confirmations) for your purchase of Brewers in Canada from June 8, 2016 until the date of the Settlement Approval Order, please check the box below, identify the applicable purchases as noted below.

Eligible for up to $25.00 in cash per household with proof of purchase. The actual amount may vary depending upon the number of claims received by the Claims Administrator. After submission, you will get a confirmation by email asking you to submit your proof by email.
Purchases of Brewers (View List of Brewers):
Product(s):
Number of brewers:
Purchase date(s):
Payment Options:
Payments to Settlement Class members shall be made by e-transfer after the period for submitting Claim Forms has expired. If the e-transfer is not successful or if a specific request is made by the Settlement Class member, payment will be made by cheque. However, there will be a deduction of CAD $3.75 per cheque if the Class Administrator makes a payment to a Settlement Class member by cheque.

Free e-transfer.

By cheque. A deduction of CAD $3.75 applies.
I UNDERSTAND THAT THE DECISION OF THE CLAIM ADMINISTRATOR IS FINAL AND BINDING ON ME AND ON KEURIG.
I DECLARE UNDER PENALTY OF LAW THAT THE INFORMATION ON THIS CLAIM FORM IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF.
Please add my email address to the mailing list to receive timely emails containing information on this class action settlement and information on other class actions settlements. Information on class action settlements includes new announcements, relevant information updates, and payout information.

Reimbursement Claim Forms will be processed and approved in accordance with the terms of the Settlement Agreement. Please check the settlement website for updates. In the event of any conflict between the terms of this Reimbursement Claim Form and the terms of the Settlement Agreement, the terms of the Settlement Agreement shall control.

The amount of reimbursement shall be limited or pro rated according to the terms of the Settlement Agreement. Please refer to the Settlement Website for more information.