SANDBOX - Invokana® Class Action Settlement

Trilogy Class Action Services - 117 Queen Street, P.O. Box 1000, Niagara-on-the-Lake, Ontario, Canada L0S 1J0|Toll Free: 1-877-400-1211|Email:

* - Required Fields

Email Address

Repeat Your Email Address

Preferred Language

Settling Claimant Identification

Your Information

First Name

Middle Name

Last Name

Mobile Phone

Home Phone

Street Number

Street Name

Street Suffix (Ave, Rd, St, etc.)

Street Direction

Unit Number (Unit 101, Suite 1B, etc.)

PO Box

City

Country

Province

Postal Code

Are you claiming on behalf of a patient or another Insured Person?

Name of the Person you are claiming on behalf of or the name of the Insured Person:
Your Relationship to the Person

First Name
Middle Name
Last Name
Preferred Language
Email Address
Mobile Phone
Home Phone
Street Number
Street Name
Street Suffix (Ave, Rd, St, etc.)
Street Direction
Unit Number (Unit 101, Suite 1B, etc.)
PO Box
City
Country
Province
Province
Postal Code