Submit Claim | Airgas Settlement

AIRGAS CLASS ACTION SETTLEMENT CLAIM FORM

To qualify for any award, you must either: (i) have a written and fully executed Cylinder Product Sales Agreement with Airgas USA, LLC ("Airgas") and paid a Fuel Surcharge during the Class Period; (ii) have a written and fully executed Bulk Product Sales Agreement with Airgas and paid a Fuel Surcharge during the Class Period, or (iii) have no written and fully executed agreement with Airgas, but have paid a Fuel Surcharge for purchases during the Class Period, as documented on an Airgas Invoice and/or Delivery Order.
The Class Period includes January 1, 2014 through December 20, 2020.
The award is not intended to provide any compensation for any charges for which you were reimbursed by another person. Do not submit a claim form for those charges (in such event, please forward the form to the person or entity that reimbursed you for the charges or contract the Settlement Administrator). The Claim Form may be subject to audit, verification and court review.
If you intend to submit a claim, please sign and date this form below, and mail this completed form to the Settlement Administrator at Angeion Group, Attn: Airgas Settlement Administrator, 1650 Arch Street, Suite 2210, Philadelphia, PA 19103. Your signed Claim Form must be received by the Settlement Administrator no later than May 1, 2021; otherwise, you will not be eligible to receive a refund as part of the Settlement.

Corporate Link (if known and applicable)

Customer Account Number(s)

Full legal name as it appears or appeared on your contract with and/or invoices from Airgas *

Principal billing address (your check will be mailed here):

Street Address *

City *

State *

Zip Code *

Daytime Telephone Number

Email Address *

* Required Fields

Airgas maintains records in its systems of the eligible charges you paid during the Class Period. If you received this notice, Airgas's records indicate that you may be a member of the class that paid one or more of these charges. Airgas's records will be used to calculate the value of your claim under the terms of the Settlement Agreement, as approved by the Court. If you don’t want to rely on this information, you may—but are not required to—submit any and all invoices you have from Airgas which will be used to create as complete a record as possible to determine the value of your claim. Enclose such invoices with this claim form.

I agree to be paid based on the total fees paid amount provided by Airgas:

Yes

If Yes, proceed to Claim Certification.

If No, provide the amount of Fuel Surcharge paid to Airgas USA, LLC, during the Class Period. You must provide documentation supporting the total amount claimed, if you elect this option.

Documentation

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CERTIFICATION

I have read the Notice and I understand that by submitting this Claim Form, I HEREBY CERTIFY (check the appropriate boxes) that:

(a) I paid Airgas USA, LLC a Fuel Surcharge documented on Airgas' Invoice or Delivery Order, during the Class Period;

and

(b) (Choose one)

1. I am a party to a Cylinder Product Sales Agreement with Airgas;

2. I am a party to a Bulk Product Sales Agreement with Airgas; or

3. I do not have a cylinder product sales agreement or a bulk product sales agreement but I paid a fuel surcharge to Airgas

I understand that the amount of my payment will be based on the records of Airgas USA, LLC and the charges paid in full, as shown by those records, unless I elect to identify transactions for which I paid, and was not reimbursed, for the charges.

I declare under penalty of perjury under the laws of the United States of America that the information provided on this form is true and correct to the best of my knowledge. I understand that my Claim Form may be subject to audit, verification, and Court review.

Signature *

Date

TALLAHASSEE PEDIATRIC DENTISTRY, PLLC; et al. vs. AIRGAS USA, LLC

Case No.: 2020-00006

Superior Court of Dougherty County State of Georgia

AIRGAS CLASS ACTION SETTLEMENT CLAIM FORM

Your Claim Form has been submitted successfully.

Submitted Claim ID:
Confirmation Code:
You will need the above Submitted Claim ID and Confirmation Code if you would like to edit your Claim at a later time, so please print this page for your records.
CLAIM INFORMATION
Full Name
Street Address
City
State
Zip Code
Daytime Telephone Number
Email Address