Bureau en Gros - Extended Service Repair Plan

CLAIM FORM

Jean-Michel Normandin v. Bureau en Gros (Staples Canada ULC.)

(500-06-000547-105)

Your duly completed claim form must be submitted no later than March 31, 2023, failing which you will be deemed to have waived your right to submit a claim and your right to any compensation, damages or remedy of any kind.

SECTION A: CONTACT INFORMATION AND PAYMENT METHOD

Provide your name and contact information below. If your contact information changes after you submit this claim form, please provide the new information to the Claims Administrator.

First Name (Required)

Last Name (Required)

Telephone number (Required)

Current address (Required)

City (Required)

Province (Required)

Postal Code (Required)

I would like to receive the amount I am entitled to: (Required)
By cheque
By bank transfer (see box below)

If you wish to receive the refund via bank transfer, please indicate your email address:

SECTION B: SWORN DECLARATION

By signing below and submitting this claim form, I do solemnly declare that: (Required)
I purchased an Extended Service Plan, namely a Repair Plan for electronics, notebooks, laptops, desktop computers, printers and accessories between December 15, 2007 and June 29, 2010 inclusively (Required)

I have not had the warranted goods repaired or replaced pursuant to the terms of said plan (Required)

I relied for my purchase on representations made by a Bureau en Gros associate to the effect that, if I did not purchase an extended warranty and a breakage occurred after the expiry of the manufacturer's one-year warranty, I would be responsible for the cost of repair or replacement (Required)

I had not purchased said plan for business purposes (Required)

**If you are unable to affirm one or more of the above statements, including if you purchased an Extended Service Replacement Plan, you are not entitled to any amount**

Full name (in lieu of signature): (Required)

Date:

For assistance, you may contact the Claims Administrator or class counsel:

Claims Administrator:

Velvet Payments
5900 Andover Ave.
Suite 1
Montreal, Quebec
H4T 1H5
beg@velvetpayments.com
1-888-770-6892

Class Counsel:

Cabinet BG Avocat Inc.
c/o Mtre Benoît Gamache
6090, Jarry est, suite B-4
Montréal (Qc) H1P 1V9
info@cabinetbg.ca
1-866-327-0123

OR

BGA Inc.
c/o Mtre David Bourgoin
67, Sainte-Ursule
Québec (Québec) G1R 4E7
info@bga-law.com
1-866-523-4222

CLAIM FORM

Your claim has been registered.

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