NFL Concussion Settlement Exclusion-Opt Out Form
This is the Opt Out Form for retired players to submit to the court BEFORE Oct. 14, 2014 in the NFL Concussion Settlement Exclusion. Players wishing to opt out will need to fill out this form, sign it and send it to the address on the form along with a copy of a government-issued photo ID (driver's license etc.). We also suggest sending this in via USPS Certified Mail or through delivery service that will provide proof of deliver. Keep a copy of the completed Opt Out form for your files.We are not providing legal advice but simply making all options available to retired players to make their own informed decisions. Consult your attorney if you have one.
Content
UNITED STATES DISTRICT COURT, EASTERN DISTRICT OF PENNSYLVANIA
In re: NATIONAL FOOTBALL LEAGUE PLAYERS’ CONCUSSION INJURY LITIGATION
Case No. 2:12 md-02323
REQUEST TO BE EXCLUDED FROM SETTLEMENT (Opt Out Form)
Mail (with ID) to: NFL Concussion Settlement, Attention: Claims Administrator
P.O. Box 25369, Richmond, VA 23260
I wish to exclude myself from the Settlement Class, and opt out of, the pending
Settlement in the case above. The information requested in the Settlement
Notice to do so is provided below.
Player’s Full Name, (printed): ___________________________________
Address: ___________________________________________
___________________________________________
Telephone number: ___________________________________________
Player’s Date of Birth ___________________________________________
-I have included a copy of my Driver’s License or other government issued ID with this
Request To Be Excluded From Settlement (Opt Out) Form-
Signed (By Hand): ________________________________(Player, Representative Claimant or Derivative
Claimant)
Print Name: _____________________________________
Signed on: __________________, 2014
Player (or deceased player’s representative) instructions to Opt Out:
Mail this FULLY COMPLETED “Request To Be Excluded” Opt Out form, including a copy of
Player’s Driver’s License or government ID, by U.S. Mail “Return Receipt Requested” (To receive
delivery verification. You cannot email it.) postmarked by October 14, 2014 to:
NFL Concussion Settlement, Attn: Claims Administrator, P.O. Box 25369, Richmond, VA 23260.
Keep copies of the Request, ID provided and delivery verification, and send duplicates to your
attorney in the NFL Concussion Case if you have one. You do not need an attorney to send this
Request To Be Excluded (Opt Out) form to the Court Claims Administrator.
