Source: http://docplayer.net/3356194-Wrg-asbestos-pi-trust-proof-of-claim-form-1-submit-completed-claims-to-wrg-asbestos-pi-trust-p-o-box-1390-wilmington-delaware-19899-1390.html
Timestamp: 2018-06-24 15:34:26
Document Index: 772720450

Matched Legal Cases: ['art 8', 'art 1', 'art 2', 'art 3', 'art 3', 'art 4', 'art 4', 'art 3', 'art 3', 'art 3', 'art 5', 'art 6', 'art 7', 'art 9', 'art 5', 'art 8']

WRG ASBESTOS PI TRUST PROOF OF CLAIM FORM 1. Submit completed claims to: WRG Asbestos PI Trust P.O. Box 1390 Wilmington, Delaware - PDF
WRG ASBESTOS PI TRUST PROOF OF CLAIM FORM 1. Submit completed claims to: WRG Asbestos PI Trust P.O. Box 1390 Wilmington, Delaware
Download "WRG ASBESTOS PI TRUST PROOF OF CLAIM FORM 1. Submit completed claims to: WRG Asbestos PI Trust P.O. Box 1390 Wilmington, Delaware 19899-1390"
1 1 Submit completed claims to: WRG Asbestos PI Trust P.O. Box 1390 Wilmington, Delaware Instructions for the Claim Form File your claim more efficiently. Submit and manage your claim electronically through the WRG Asbestos PI Trust s (the Trust ) website. Visit for more information. Note: It is possible that claim data previously submitted to the Delaware Claim Processing Facility for another trust can be used to expedite the preparation and review of claims for the Trust. Doing so will reduce the work necessary to file a claim and minimize the time it takes to review the claim. Please visit the Trust's website for information on the use of this data. Please complete this claim form as thoroughly and accurately as possible. Please type or print neatly. Should there be insufficient space to list all relevant information, please attach additional sheets. In addition to filing this form, please ensure the following are enclosed: Death Certificate (if applicable) Certificate of Official Capacity or other estate documentation (if personal representative is filing form) if applicable per state law Medical records as required by the Asbestos PI Trust Distribution Procedures ("TDP") and as requested in instructions Proof of Grace Exposure as required by the TDP and as set out in the instructions Documentation of Economic Loss (if applicable see Part 8 below) Choice of Claim Process Please choose the applicable claim process (check only one): Expedited Review ( ER ) (not available for Level VI (Lung Cancer 2) Claims, Secondary Exposure Claims or Foreign Claims) Individual Review ( IR ) Representation If counsel represents claimant, please print or type the following information: 1. Attorney Name: (Last) (First) (MI) 2. Name of Law Firm: 3. Firm Address: 4. Attorney Phone: ( ) Fax: ( ) 1 To the extent this form conflicts with the TDP, the TDP controls. Page 1
2 5. Paralegal or Contact Name: (Last) (First) (MI) 6. Contact Phone: ( ) Fax: ( ) Part 1: Injured Party Information 1. Name: (Last) (First) (MI) 2. Social Security Number: Gender: Male Female 4. Date of Birth: / / 5. Medicare Health Insurance Claim Number (HICN) (if applicable and known) 6. Is injured party living? Yes No 7. If injured party is deceased, please complete the following (Death Certificate must be enclosed): 7a. Date of death: / / 7b. Was death asbestos-related? Yes No 8. If injured party is living and not represented by counsel, please complete the following: 8a. Mailing address: (street/po Box) (city/state/zip) 8b. Daytime Phone: ( ) - 8c. Address: 9. If injured party is deceased or has a personal representative or heir other than, or in addition to, his/her attorney, please indicate the following for the representative. (Certificate of Official Capacity or other estate documentation must be enclosed if applicable per state law.) 9a. Name: (Last) (First) (MI) 9b. Social Security Number: - - or Tax ID Number: 9c. Mailing Address: (street/po Box) (city/state/zip) 9d. Daytime Phone: ( ) - Page 2
3 9e. Address: 9f. Relationship to injured party: (spouse, child, etc.) 10. Please provide the following information for Medicare Reporting purposes: Check this box if the injured party s Grace Exposure ended before December 5, Please note that if a claimant is unable or chooses not to answer question 10, the Trust will presume exposure on or after December 5, 1980 for Medicare Reporting purposes only. This presumption will not affect the calculation of an injured party s exposure for purposes of meeting the TDP s exposure requirements. Part 2: Diagnosed Asbestos-related Injuries 1. Place an X next to the highest level (most serious) asbestos-related Disease Category that has been diagnosed for the injured party and for which appropriate medical documentation is attached to this claim form. See instructions for a list of specific medical criteria and records that must be enclosed for each Disease Category (Check only the most serious). Level Scheduled Disease VIII Mesothelioma VII Lung Cancer 1 VI Lung Cancer 2 (Individual Review Only) V Other Cancer (Please specify: ) IV(A) Severe Asbestosis (Diagnosis of Asbestosis with ILO of 2/1 or greater, or asbestosis determined by pathology plus (a) TLC less than 65% or (b) FVC less than 65% plus FEVl/FVC ratio greater than 65%) IV(B) Severe Disabling Pleural Disease (Diagnosis of diffuse pleural thickening of at least extent "2" and at least width "a" as one component of a bilateral non-malignant asbestos related disease based on definitions as set forth in the 2000 revisions of the ILO classification, plus (a) TLC less than 65% or (b) FVC less than 65% plus FEVl/FVC ratio greater than 65%) III Asbestosis/Pleural Disease (Bilateral Asbestos-Related Non-Malignant Disease plus (a) TLC less than 80% or (b) FVC less than 80% and FEV1/FVC ratio greater than or equal to 65%) II Asbestosis/Pleural Disease (Bilateral Asbestos-Related Non-Malignant Disease) I Other Asbestos Disease (Cash Discount Payment, not subject to the Payment Percentage) Page 3
4 2. Date of Diagnosis: / / The claims must meet the relevant medical criteria and be supported by appropriate medical documentation as defined in the TDP. The presumptive medical criteria for the Disease Categories set forth above are included in the instructions. For claims filed against W.R. Grace or any other asbestos defendant in the tort system prior to the Petition Date (April 2, 2001), please check this box if you have a report of a diagnosing physician who conducted the physical exam of the injured party, or you have filed such a report with W. R. Grace or another defendant in the tort system or another asbestos-related personal injury settlement trust. (see Sections 5.7(a)(1)(A) and 5.7(a)(1)(C) of the TDP) Part 3: Grace or Other Asbestos Exposure and Significant Occupational Exposure Proof of Grace Exposure and proof of Significant Occupational Exposure to all asbestos-related products are addressed below and must be supplied as required by TDP sections 5.3 and 5.7(b) (See instructions). Please photocopy this section and list separately each company site, industry, and occupation combination upon which you rely to meet the exposure requirements of the TDP. "Grace Exposure" means (i) meaningful and credible exposure, which occurred prior to December 31, 1982 to (a) any products or materials containing asbestos that were manufactured, sold, supplied, produced, specified, selected, distributed or in any way marketed by W. R. Grace and/or any of the Debtors (collectively "Grace") (or any past or present Grace Affiliate, or any of the predecessors of Grace or any of their past or present Affiliates, or any other Entity for whose products or operations Grace allegedly has liability or is otherwise liable) or (b) asbestos-containing winchite asbestos or asbestos-containing vermiculite mined, milled or processed by Grace (or any past or present Grace Affiliate, or any of the predecessors of Grace or any of their past or present Affiliates, or any other Entity for whose products or operations Grace allegedly has liability or is otherwise liable) or (ii) meaningful and credible exposure which occurred prior to the Effective Date to (a) asbestos, asbestos-containing winchite asbestos or unexpanded asbestos-containing vermiculite ore in Lincoln County, Montana or (b) asbestos, asbestoscontaining winchite asbestos or asbestos-containing vermiculite ore from Lincoln County, Montana during transport or use prior to the completion of a finished product at an expansion plant. Please include detail concerning asbestos exposure (not just Grace Exposures) necessary to meet the exposure criteria for approval of the claim at the claimed disease level. List each site, industry, and occupation combination separately. For Grace Exposures, a list of approved Grace sites is available on the Trust website (www.wrgraceasbestostrust.com). Please reference this list and enter the Approved Grace Site Code in item #1 below. If the site at which you are alleging exposure to Grace's products or activities is not on the approved Grace site list, provide independent documentation of meaningful and credible evidence of exposure to asbestoscontaining products or activities for which Grace is liable. This may be established by documentation including, but not limited to, the following: - An affidavit of the injured party - An affidavit of a co-worker - An affidavit of a family member in the case of a deceased claimant - Invoices - Construction or similar records - Sworn statement, interrogatory answers, sworn work history, or deposition Page 4
5 (Part 3, continued) 1. Site/Plant/Ship where Exposure Occurred: If the site is on the Grace approved site list, enter the Site Code from Exhibit A (available on website): Approved Site Code (see Exhibit A): If a Site Code is entered, please skip to question 2, otherwise provide: Name of Ship/Plant/Site of Exposure: City: State/Province: Country: If this exposure involved products manufactured, sold, supplied, produced, specified, selected, distributed, or in any way marketed by Grace, or for which Grace is responsible, identify the products and provide the evidentiary basis for the claim that these products were at that site: 2. Date Exposure began: / Date Exposure ended: / (month) (year) (month) (year) 3. Occupation at time of Exposure (e.g., Boilermaker, Laborer, etc.): 4. Industry in which Exposure occurred: (Industry codes listed below) If Code 37 - Other, please describe: Industry Codes 10. Asbestos mining 24. Petrochemical 11. Aerospace/aviation 25. Insulation 12. Asbestos abatement 27. Railroad 13. Automobile/mechanical friction 30. Shipyard-construction/repair 16. Chemical 31. Textile 17. Construction 32. Tire & rubber 18. Iron/steel 33. Utilities 19. Longshore 34. Asbestos products manufacturing 20. Maritime 36. Building occupant /bystander 21. Military 37. Other 23. Non-asbestos products manufacturing Page 5
6 5. Significant Occupational Exposure (SOE) If the injured party s occupation does not appear on the list of Presumptive SOE Occupations Ratings (available at please skip to question 6. If it does appear on the list, indicate circumstances of exposure to asbestos products or activities (check all applicable): The injured party handled raw asbestos fibers on a regular basis The injured party fabricated asbestos-containing products such that the injured party in the fabrication process was exposed on a regular basis to raw asbestos fibers The injured party altered, repaired or otherwise worked with an asbestos-containing product such that the injured party was exposed on a regular basis to asbestos fibers The injured party was employed in an industry or occupation such that the injured party worked on a regular basis in close proximity to workers who did one or more of the above three activities None of the above 6. If the injured party s occupation does not appear on the list of Presumptive SOE Occupations Ratings, or None of the above was checked in question 5 above, provide a description of how the injured party was exposed to asbestos at each relevant site. 7. Grace Exposure. Every claimant must submit evidence of exposure to Grace asbestos products or activities. For claimants whose exposure is described in clause (ii) of the definition of Grace Exposure on page 5 herein ( Libby Claimants ) and who are not claiming occupational exposure at the Libby Mine or Mill, check box 6 below and move directly to section 7(c). a. To demonstrate exposure to Grace products or activities, check the applicable box below. If you check box 5, answer question 7(b). If any of the first four boxes are checked, proceed to question #8. Provided, however if box #1 is checked and there is no date on the site list, question 7(b) must be answered. (check one box only) 1. The site in question 1 is on the Grace approved site list, and the injured party worked there during the appropriate time period (if there is no date on the site list, please answer the question 7(b) below); or 2. Claimant s answer to question 1 is the injured party s personal identification of exposure to Grace's asbestos products/activities; or 3. Claimant s answer to question 1 otherwise identifies Grace s asbestos products/activities at this site (e.g. coworker affidavit), and also identifies the injured party by name; or 4. The answer to question #1 provides evidence that Grace s asbestos products or activities were at this site and further sets forth that the injured party worked at this site within a year of having demonstrated that the asbestos products or activities were present at the site; Page 6
7 5. 6. None of the above apply and the injured party is not a Libby Claimant; or Claimant is alleging exposure to (a) asbestos, asbestos-containing winchite asbestos or unexpanded asbestos-containing vermiculite ore in Lincoln County, Montana or (b) asbestos, asbestos-containing winchite asbestos or asbestos-containing vermiculite ore from Lincoln County, Montana during transport or use prior to the completion of a finished product at an expansion plant. b. If the box 5 was checked, or if box 1 was checked and there is no date on the site list, provide a description of the injured party s exposure to the type of asbestos products or activities that you have attributed to Grace at this site: c. If box 6 was checked, provide a description of the injured party s exposure to asbestos, asbestos-containing winchite asbestos or unexpanded asbestos-containing vermiculite ore in Lincoln County, Montana. For exposures within Lincoln County, please provide the location(s) of exposure (ex. home or business address) and state the relevant time period for each location. For transport or use exposures, please provide the exposure site and a description of the injured party s exposure including occupation, if relevant. Attached additional sheets if necessary. 8. If this exposure is in support of Exposure to an Occupationally Exposed Person from Part 4 hereunder, please enter the name of the occupationally exposed individual: (Last) (First) (MI) Page 7
8 Part 4: Exposure to an Occupationally Exposed Person Note: If a claimant alleges an asbestos-related disease resulting solely or in part from exposure to an occupationally exposed person, such as a family member, the claimant must seek Individual Review of his or her claim pursuant to Section 5.5 of the Trust Distribution Procedures. See Choice of Claim Process box on first page of this claim form. 1. Is the claimant alleging an asbestos-related disease resulting in whole or in part from another person s occupational exposure, such as a family member (spouse, parent, sibling, etc.)? Yes No If yes, Part 3 must also be completed for each occupationally exposed person. 2. Date injured party s Exposure to other person began: / (month) (year) 3. Date injured party s Exposure to other person ended: / (month) (year) 4. Injured party s relationship to occupationally exposed individual during the exposure period: (brother, son, spouse, etc.) 5. Occupationally exposed individual information 5a. Name: (Last) (First) (MI) 5b. Social Security Number Describe how injured party was exposed through the occupationally exposed individual to the Grace product or conduct: Reminder: Part 3 must be completed for the occupationally exposed person. If the injured party also had direct, occupational exposure to asbestos, Part 3 must also be completed for that exposure. Page 8
9 Part 5: Litigation/Claims History 1. Has an asbestos-related lawsuit ever been filed on behalf of the injured party? Yes No a. Was Grace named as a defendant? Yes No b. State in which the suit was originally filed: c. Name of the court in which the suit was originally filed: d. Case number: e. Date the suit was originally filed: / / f. Have you received money from Grace regarding this suit? Yes No g. Did you sign a release releasing Grace regarding this suit? Yes No 2. If the answer to question 1(a) above is Yes, was a final non-appealable judgment entered? Yes No 2a. If the answer to question 2 above is Yes, provide a copy of the judgment. 2b. If the answer to question 2 above is No, was an appeal filed by Grace or the plaintiff in connection with the suit? Yes No 2c. If the answer to question 2b above is Yes, please provide the case number of the appeal and indicate whether a letter of credit, appeal bond, supersedeas bond or other security or surety was issued in connection with the appeal, verdict, or judgment. 3. If the answer to question 1(a) above is No, in which state/jurisdiction would the claimant qualify to be evaluated pursuant to TDP section 5.3(b)(2)? 3a. Is this the state/jurisdiction where the claimant resided at the time of diagnosis? Yes No 3b. Is this the state/jurisdiction where the claimant had Grace Exposure? Yes No 3c. Is this the state/jurisdiction where the claimant resided at the time of the filing of this claim? Yes No 4. Was a tolling agreement for the injured party ever in effect with respect to the claim(s) against Grace? Yes No If Yes, please submit copy of tolling agreement. a. Date the tolling agreement began: / / b. Date the tolling agreement ended: / / 5. Was a claim filed with Grace pursuant to an administrative settlement agreement? Yes No a. Date the claim was originally filed: / / b. Have you received money from Grace re: this claim? Yes No Page 9
10 Part 6: Financial Dependents and Beneficiaries WRG ASBESTOS PI TRUST List any other persons who may have rights associated with this claim. Be sure to include the injured party s spouse and/or any other financial dependents who derive (or who derived at the time of diagnosis of the asbestos-related disease claimed) at least one-half of their financial support from the injured party. This must be completed for IR claims only. If additional space is required, please photocopy this page and insert after current page. 1. Name: 2. Date of Birth: / / (Last) (First) (MI) 3. Relationship: Spouse 4. Financially Dependent: Yes Child Heir Other No 1. Name: 2. Date of Birth: / / (Last) (First) (MI) 3. Relationship: Spouse 4. Financially Dependent: Yes Child Heir Other No 1. Name: 2. Date of Birth: / / (Last) (First) (MI) 3. Relationship: Spouse 4. Financially Dependent: Yes Child Heir Other No 1. Name: 2. Date of Birth: / / (Last) (First) (MI) 3. Relationship: Spouse 4. Financially Dependent: Yes Child Heir Other No Page 10
11 Part 7: Smoking History For each item, indicate whether the injured party has smoked. Please indicate the dates cigarettes or cigars were used, and the amount per day. Indicate fractional packs or fractional cigars as appropriate, e.g., three and one-half packs would be entered as 3.5. This is to be completed for Lung Cancer 2 (LC2) and IR levels II through VII only. 1. Has the injured party ever Smoked Cigarettes? Yes No 1a. From: / To: / (month) (year) (month) (year) 1b. Packs per day: (use decimal) 1. Has the injured party ever Smoked Cigars? Yes No 1a. From: / To: / (month) (year) (month) (year) 1b. Cigars per day: (use decimal) Page 11
13 Part 9: Signature Page All claims must be signed by the claimant, or the person filing on his/her behalf (such as the personal representative or attorney). If signed by the claimant or the personal representative, I (the claimant or personal representative) have reviewed the information submitted on this claim form and all documents submitted in support of this claim. Upon information and belief, I hereby certify, under penalty of perjury, that the information submitted is accurate. If signed by the claimant s counsel, upon information and belief, I hereby certify, under penalty of perjury, that the information submitted is accurate. Signature of claimant, personal representative, or claimant s counsel. Please print the name and relationship to the claimant of the signatory above. Date: / / Please review your submission to ensure it is complete and includes the following documents as applicable. Death Certificate (if applicable) Certificate of Official Capacity or other estate documentation (if personal representative is filing form) if applicable per state law. Medical Records as required by the TDP and as requested in the instructions Proof of Grace Exposure and Significant Occupational Exposure as required in the TDP and requested in the instructions, including affidavits or sworn statements from the injured party or others. Copy of the tolling agreement (if applicable in Part 5) Documentation of economic loss (if Part 8 is applicable) Any additional information you wish to provide If you are filing an IR claim and have additional information (see TDP section 5.3(a)(2)) you want the Trust to consider in evaluating your claim, please include these documents with the Claim Form. Page 13