Wagners.co



1869 Upper Water StreetSuite PH 301, Pontac HouseHALIFAX, NS B3J 1S9wagners.co Email: classaction@wagners.co DELL PRIVACY BREACHCLASS ACTION INTAKE FORMDate: ______________________Please note: we will keep confidential any personal identifying information that you provide on this form, subject to first receiving permission from you.How did you learn about the proposed class action lawsuit? _________________________SECTION I: CONTACT INFORMATIONClaimant’s NameFirst Middle LastOther names Claimant may be known as, if any (including maiden name, if applicable):First Middle LastFirst Middle LastClaimant’s Date of Birth: Claimant’s Place of Birth: Claimant’s Health Card #: Province Health Card Issued: Claimant’s Mailing Address:Email: Home Phone: Cell Phone: Other Phone: Facsimile: Claimant’s Preferred Form of Contact:Email: Reg. Mail: Phone: Contact Person (If Other Than Claimant) and His/Her Contact Information:Name: ______________________________Relationship to Claimant: _______________Address (Mailing):Email: Home Phone: Cell Phone: Other Phone: Facsimile: Preferred form of contact:Email: Reg. Mail: Phone: Claimant’s Marital Status: (Please Circle) Single / Married / Common Law Divorced / Widowed / Separated SECTION II: PRIVACY BREACH INFORMATIONDell used a service provider (the “Provider”) to deliver customer support in a call centre located in India. Employees of the Provider were found to have inappropriately disclosed Dell customer data lists to third parties in June and November of 2017. Dell is unaware what information was breached in the June 2017 breach. Dell was able to confirm that the personal information of approximately 7,883 Canadian Dell customers was breached and sold to a third party in November of 2017. It may be that some Canadian Dell customers’ information was breached in both breaches. PART A: JUNE 2017 PRIVACY BREACHDid you purchase Dell products or speak with Dell customer service or tech support between January 2008 and June 2017?Yes: _______ No: __________ If Yes to Question 1, did you provide Dell with your personal information when purchasing products or speaking with Dell customer service or tech support between January 2008 and June 2017? Personal information includes but is not limited to name, address, email address, telephone numbers, credit card numbers, and social insurance number.Yes: _______ No: __________If Yes to Question 2, in or after June 2017, have you received, or do you suspect you’ve received, Targeted Tech Support Scam calls, emails or other correspondence claiming to pertain to your Dell product or service? Targeted Tech Support Scams include circumstances in which the scammer poses as an employee of Dell and has your personal information (including name, address, email address, telephone numbers, credit card numbers, social insurance number, and private correspondence) and/or private customer information (including but not limited to non-public information about Dell product model numbers, service tags, express service codes, prior product service histories and interactions, and warranty information). Yes: _______ No: __________PART B: NOVEMBER 2017 PRIVACY BREACHDid you purchase Dell products or speak with Dell customer service or tech support between January 2008 and November 2017?Yes: _______ No: __________ If Yes to Question 4, did you receive email correspondence from Dell Technologies in April 2018 advising that Dell “had determined that scammers claiming to work for Dell have some basic information related to your Dell services history (such as customer name, email address, Dell product information, Dell service tag or Dell support history)”? Yes: _______ No: __________In or after November 2017, have you received, or do you suspect you’ve received, Targeted Tech Support Scam calls, emails or other correspondence claiming to pertain to your Dell product or service?Yes: _______ No: __________PART C: GENERAL INFORMATION RE PRIVACY BREACH(ES)How were you contacted by the Targeted Tech Support Scammers (please check all that apply)?Phone: ______Email: ______Other: ______________________________Approximately how long did you continue to receive Targeted Tech Support Scam calls, emails or other correspondence claiming to pertain to your Dell product or service? From: ______________________________To: ______________________________Did you change your phone number and/or email address to stop receiving Targeted Tech Support Scam calls, emails or other correspondence?Yes: _______ No: __________Did you provide your personal information or your Dell private customer information, which includes but is not limited to your name, email address, Dell product information, Dell service tag or Dell support history to suspected Targeted Tech Support Scam calls, emails or other correspondence, believing you were providing the information to Dell?Yes: _______ No: __________If Yes to Question 10, please list the type of information you provided:To your knowledge, was malicious software installed on your Dell product? Yes: _______ No: __________Did you contact Dell to advise them of the suspected Targeted Tech Support Scam calls, emails or other correspondence you received?Yes: _______ No: __________If Yes, when: ______________If Yes to Question 13, what response did you receive from Dell?If you have correspondence between you and Dell regarding your complaint(s) concerning Targeted Tech Support Scam calls, emails or other correspondence, we ask that you include a copy with this Intake Form.As a result of receiving Targeted Tech Support Scam calls, emails or other correspondence, did you suffer any of the following? Please check all that apply:Inconvenience Psychological distressAnguishFrustrationAnxietyStressOther: __________________________________________________________________Please provide any further details you consider relevant in describing how receiving Targeted Tech Support Scam calls, emails or other correspondence impacted you:SECTION III: INCOME LOSS / OUT OF POCKET EXPENSESDid you provide your banking information either via telephone, email or other correspondence to scammers, believing you were providing such information to Dell? Yes: _______ No: _________ Unsure: _________If Yes, was this information used to acquire funds (money) from you? Yes: _______ No: _________ Approximate amount (CAD): ______________________ Have you suffered or experienced any financial loss as a result of receiving Targeted Tech Support Scam calls, emails or other correspondence? Yes: _______ No: __________ Unsure: __________Approximate amount (CAD): ______________________ Did you incur any expenses (e.g., need for computer remediation after installation of malicious software, to run a credit check, purchase of third-party credit protection and anti-fraud monitoring, etc.) as a result of receiving Targeted Tech Support Scam calls, emails or other correspondence? Yes: _______ No: __________ Unsure: __________Approximate amount (CAD): ______________________ If so, we ask that you please save all receipts / documentation of expenses for the time being.Please generally describe how as a result of receiving Targeted Tech Support Scam calls, emails or other correspondence impacted your activities of daily living, enjoyment of life (etc.)SECTION IV: OTHER INFORMATIONPlease provide any further information that you think may be relevant:Thank you for completing this informational form. Upon receiving your contact information, we will add you to our database and will provide you with any relevant updates on the action. Please note that individual interviews and meetings are not required at this time. ................
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