Submit a Dispute
If you received a Relevant Payments Notice and wish to submit a Dispute Form online, please provide the information below and upload your completed Dispute Form and the supporting documentation in the required format. Alternatively, you may complete, sign and mail, together with your supporting data, the hard copy Dispute Form you received with the Relevant Payments Notice. Please read the Dispute Form instructions carefully.
To submit a dispute online, provide the information below, then upload your completed Dispute Form and supporting documentation on the next page.
The deadline to submit a Dispute Form and all supporting documentation is December 20, 2021. If you submit your Dispute Form and supporting data by mail, the envelope must be postmarked by December 20, 2021.
If you wish to submit supporting data on a password-protected storage device (rather than upload it on this website), please provide the password in the space provided in your Dispute Form and mail the storage device to the Claims Administrator at UFCW & Employers Benefit Trust v. Sutter Health c/o Administrator, P.O. Box 6389, Portland, OR 97228-6389. Label the storage device with your full name, address, and the unique identification number on your Dispute Form.
For more information, contact Class Counsel at email@example.com.