Enoxaparin Antitrust Settlement

Hospital Class Member Only

Authorized Agents only

Hospital Class Member Only

Hospital Name: *

Contact Name:

Address 1: *

Address 2:

City: *

State: *

Zip: *

Area Code - Telephone Number: *

Tax Identification Number: *

Email Address:

List other names by which your hospital has been known or other Federal Employer Identification Numbers ("FEINs") it has used since September 21, 2011:

Authorized Agents only

Authorized Agent's Company Name: *

Contact Name:

Address 1: *

City: *

State: *

Zip: *

Area Code - Telephone Number: *

Authorized Agent's Tax Identification Number: *

Email Address:

Please list the name and FEIN of every Class Member (i.e., Hospital) for whom you have been duly authorized to submit this Claim Form (attach additional sheets to this Claim Form as necessary). Alternatively, you may submit the requested list of Class Member names and FEINs in an electronic format, such as Excel or a tab-delimited text file saved on a disk. Please contact the Notice and Claims Administrator to determine what formats are acceptable.

Class Member Name:

Class Member Fein:

Click Add Class Member to add to submission.

Class Member's Name

Class Member's FEIN

Action

Purchase Information

Please type or print in the box below, the total amount paid for Lovenox® or generic enoxaparin in

Arizona, Arkansas, California, District of Columbia, Florida, Hawaii, Illinois, Iowa, Kansas, Maine, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Mexico, New York, North Carolina, North Dakota, Oregon, South Dakota, Tennessee, Utah, Vermont, West Virginia, and Wisconsin, other than for resale,

from September 21, 2011 through September 30, 2015.

Total Amount You Paid For Lovenox®

Total Amount You Paid For Generic Enoxaparin

Proof of Payment

Please provide as much as possible of the information described in the “CLAIM DOCUMENTATION REQUIREMENTS” section of the instructions above. The requested information is by default mandatory for claims of $300,000 or more, although the Notice and Claims Administrator may also require documentation for claims of less than $300,000. For claims of less than $300,000, you should still provide the information if you can, even if not specifically requested by the Notice and Claims Administrator. Claims that do not have sufficient documentary support may be rejected.

Please use the browse option, by clicking on “Select Files” in the box below to upload your supporting documentation.

Select files

Files To Be Uploaded	Size	Action

Certification

I have read and am familiar with the contents of the Instructions accompanying this Claim Form. I certify that the information I have set forth in the above Claim Form and in any documents attached by me are true, correct and complete to the best of my knowledge. I certify that I or the Class Member I represent paid the total amount set forth above in out-of-pocket expenditures for purchases of Lovenox® or generic enoxaparin in Arizona, Arkansas, California, District of Columbia, Florida, Hawaii, Illinois, Iowa, Kansas, Maine, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Mexico, New York, North Carolina, North Dakota, Oregon, South Dakota, Tennessee, Utah, Vermont, West Virginia, and Wisconsin during the period from September 21, 2011 through September 30, 2015. I further certify that I or the Class Member I represent did not opt out of the Class in this Action. Nor did I or the represented Class Member purchase such Lovenox® or generic enoxaparin for purposes of resale. In addition, I have not (or the represented Class Member has not) served as counsel, officer, director, agent, or employee of any of the Defendants, or a corporate parent, subsidiary, affiliate, or other related entity thereof; or served as a judge or justice assigned to hear any aspect of this lawsuit.

To the extent I have been given authority to submit this Claim Form by a Class Member on its behalf, and accordingly am submitting this Claim Form in the capacity of an Authorized Agent with authority to submit it by the Class Member identified on a separate sheet of paper submitted with this form, and to the extent I have been authorized to receive on behalf of this Class Member(s) any and all amounts that may be allocated to it from the Settlement Fund, I certify that such authority has been properly vested in me and that I will fulfill all duties I may owe the Class Member. In the event amounts from the Settlement Fund are distributed to me and a Class Member later claims that I did not have the authority to claim and/or receive such amounts on its behalf, I and/or my employer will hold the Class, counsel for the Class, and the Notice and Claims Administrator harmless with respect to any claims made by the Class Member.

I hereby submit to the jurisdiction of the United States District Court for the Middle District of Tennessee for all purposes connected with this Claim Form, including resolution of disputes relating to this Claim Form. I acknowledge that any false information or representations contained herein may subject me to sanctions, including the possibility of criminal prosecution. I agree to supplement this Claim Form by furnishing documentary backup for the information provided herein, upon request of the Notice and Claims Administrator.

Claimant Signature: *

Position/Title: *

ACCURATE CLAIMS PROCESSING TAKES A SIGNIFICANT AMOUNT OF TIME. THANK YOU FOR YOUR PATIENCE.

Reminder Checklist:

1. Please complete and sign the above Claim Form. Attach or upload any documentation supporting your claim.

2. Keep a copy of your Claim Form and supporting documentation for your records.

3. If you would also like acknowledgement of receipt of your Claim Form, please complete the form online or mail this form via Certified Mail, Return Receipt Requested.

4. If you move and/or your name changes, please send your new address and/or your new name or contact information to the Notice and Claims Administrator via the Settlement Website or U.S. Mail (the addresses are listed above).