Individual Class Action Claims: Claims Form - LIPA Outage Claims for Loss

Individual Class Action Claims

Name:

Address:

City:

Zip Code:

Home Phone Number:

Cell Phone Number:

Work Phone Number:

Email Address:

Type of residence:

Date Outage Started:

Select Date

Date Outage Ended:

Select Date

How many days was your home without power for?:

What is the nature of your loss as a result of being out of power?:

Would you like to serve as a Class Representative in a Class Action against LIPA?:

Yes
No

Kenneth Mollins PC | Parker Waichman LLP | Douglas & London

Disclaimer: Please note that by submitting this information, you are not filing a Notice of Claim with LIPA. As a law firm, we must first receive a signed retainer agreement after we have reviewed and accepted your case. Once retained, we can then file a Notice of Claim on your behalf.