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Northwood Halifax COVID-19-Related Deaths

1869 Upper Water Street
Suite PH 301, Pontac House
HALIFAX, NS B3J 1S9
www.wagners.co
Email: [email protected]

Please note: we will keep confidential any personal identifying information that you provide on this form, subject to first receiving permission from you.

Please complete this form if you wish to be kept informed of the progress of this case.

Completing this form creates no financial obligation for you. It does not create a lawyer/client relationship between yourself and Wagners (or any of its lawyers).

By completing this form you are asking Wagners to include you in our list of potential members in this class action, but our firm is not agreeing to represent your personal interests. Wagners will represent the interests of the class as a whole.

The definition of the class of people included in this class action may in the future change or be modified. We may not inform you or the public if and when the class definition changes.  It is your responsibility to ensure that your own personal interests and legal rights are being protected. You may wish to obtain independent legal advice in order to determine whether it would be in your best interest to pursue independent litigation in this matter. Should you meet the definition of a class member, you may be entitled to compensation if there is a final judgment or settlement in favour of the class. However, the class definition may change over time, and there is no guarantee of compensation regardless of the class definition.

NORTHWOOD HALIFAX COVID-19 RELATED DEATHS

CLASS ACTION INTAKE FORM

  • THIS FORM IS FOR INFORMATIONAL PURPOSES ONLY. IT IS NOT A CLAIM FORM AND DOES NOT GUARANTEE ELIGIBILITY FOR ANY EVENTUAL COMPENSATION.
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  • SECTION I: INFORMATION OF THE NORTHWOOD RESIDENT

  • Other names the Resident may be known as, if any (including maiden name, if applicable):

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  • SECTION II: SURVIVING FAMILY MEMBER INFORMATION

  • Under the Fatal Injuries Act (FIA), the executor or administrator of the deceased’s estate, or a family member entitled to bring a claim under the FIA (spouse, common-law partner, parents, children, grandchildren or stepchildren of the deceased) may pursue a claim for fatal injury damages.
  • Name of the Person who has Contacted Wagners and Contact Information:

  • Claimant 1:

  • If able, please complete the below information for all surviving family members who would qualify under the Fatal Injuries Act (FIA), (spouse, common-law partner, parents, children, grandchildren or stepchildren of the deceased). If further space is required, please feel free to attach an additional page:
  • (1)

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  • (2)

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  • (3)

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  • (4)

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  • (5)

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  • (6)

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  • SECTION III: NORTHWOOD RESIDENT WILL/ESTATE INFORMATION

  • SECTION IV: NORTHWOOD INFORMATION

  • PART A: RESIDENCE DETAILS at Northwood

  • What was the Resident’s Level of Care in:

  • We ask that you please save all emails / notes from calls regarding contact with Northwood. If you have them in your possession, and are willing to share them, please include copies along with this form.
  • PART B: COVID-19 RELATED DETAILS AT NORTHWOOD

  • SECTION V: OTHER INFORMATION

  • 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.