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CLAIM FORM & DECLARATION MLC Asbestos PI Trust - PDF
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1 MLC Asbestos PI Trust Submit claims to: Website- mfrclaims.com Or - Or Mail to- MLC Asbestos PI Trust c/o MFR Claims Processing, Inc. 115 Pheasant Run Suite 112 Newtown, Pa For additional information, please refer to the Instructions for Filing a Claim with the MLC Asbestos PI Trust and the MLC Asbestos PI Trust Distribution Procedures (the TDP ).
2 Please review the instructions before completing this claim form. Please complete this claim form as thoroughly and accurately as possible. All applicable questions must be answered. Please type or print neatly. Should there be insufficient space to list 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 Personal Injury Trust Distribution Procedures ( TDP ) and as requested in the instructions - Proof of Old GM Exposure as set out in the instructions - Documentation of Economic Loss (if applicable) Part 1: INJURED PARTY and CLAIM INFORMATION 1.1 Claim Type: CHECK ONLY ONE BOX BELOW Auto Mechanic Claim- In order for a claimant to qualify as an auto mechanic under this TDP, said claimant must have worked professionally as a mechanic in the automotive servicing and repair industry performing work on General Motors marine engines, brakes and/or clutches on cars, trucks, buses, or other vehicles. This work typically would have involved changing brakes and brake pads as well as clutches and clutch facings or other similar General Motors friction products such as Electro-Motive railroad friction products. Also included under this definition of auto mechanic are individuals who worked alongside such brake mechanics, but in another capacity, including but not limited to those individuals working in said industry as body repairmen, parts department employees, or persons who cleaned up the facilities where such brake and clutch work was done. Other Claim- Claims held by persons other than auto mechanics, including but not limited to shade tree mechanics, automobile hobbyists, individuals who occasionally performed brake and/or clutch work on their own vehicles and/or the vehicles of friends and neighbors, or any other individuals who were not regularly employed as professional auto mechanics. 1.2 Injured Party s Full Name: [First Name] [Middle Name] [Last Name] SSN: - - Date of Birth: / / Month Day Year Gender: M F Injured Party's Contact Information (If Injured Party is living and not represented by Counsel) Address: Street: City: State: Zip Code: Phone: 1 of 15
3 1.3 Is the Injured Party Living? Yes No If No, provide the following: Date of Death: / / Month Day Year Was the Death Asbestos related? Yes No Personal Representative s Full Name: [First Name] [Middle Name] [Last Name] Address: Street: City: State: Zip Code: Phone: Relationship to Injured Party?: Also provide Death Certificate and one of the Following (if required by state law) : Certificate of Official Capacity Other applicable document authorizing a person to act on behalf of the Injured Party 1.4 If represented by Counsel, Injured Party s Law Firm Contact Information If claimant is not represented by counsel, please provide Claimant contact information above. Firm Name: Attorney Name: Phone Number: Para/ Admin Name: Phone Number: Address: 2 of 15
4 1.5 Review of claim: Please check the appropriate box: Expedited Review (NOT available for Lung Cancer 2, Foreign, Extraordinary or Secondary Exposure Claims) Individual Review (Complete and Submit Both General and Individual Review Sections of this Claim Form) Foreign Claim (this box should be checked if the claimant s exposure to an asbestos-containing product or conduct for which Old GM has legal responsibility occurred outside of the United States and its Territories and Possessions, and outside of the Provinces and Territories of Canada.) 3 of 15
5 Part 2: DIAGNOSED DISEASES DISEASE CLAIMED Check the box indicating the highest disease level for which the Injured Party has been diagnosed. Attach medical evidence to support the claim. Provide the date of first diagnosis for the disease claimed. See Instructions for Filing a Claim with the MLC Asbestos PI Trust for the applicable medical evidence required for each disease. Disease Level I Asbestosis/Pleural Disease I First Date of Diagnosis Disease Level II Asbestosis/Pleural Disease II Disease Level III Severe Asbestosis Disease Level IV Other Cancer Colorectal Cancer Esophageal Cancer Laryngeal Cancer Pharyngeal Cancer Stomach Cancer Disease Level V Lung Cancer 2 (IR ONLY) Disease Level VI Lung Cancer 1 Disease Level VII Mesothelioma For claims filed against Old GM or any other asbestos defendant in the tort system prior to the Commencement Date, please check this box if you have available a report of a diagnosing physician, engaged by the claimant or his or her counsel, who conducted a physical exam of the claimant, or you have filed such a report with another asbestos-related personal injury settlement trust. (see sections 5.7(a)(1)(A) and 5.7 (a)(1)(c) of the TDP). 4 of 15
6 Please note that the Commencement Date is June 1, 2009 except with respect to Remediation and Liability Management Company, Inc. and Environmental Corporate Remediation Company, Inc. In the case of those entities, the Commencement Date is October 9, Part 3A: Ordering, Processing and Payment of Claims Applicable from to [Use actual dates] Provide the date for the applicable category or categories. From Section 5, Page 18 of the TDP. (i) the date prior to the Commencement Date that the specific claim was either filed against a Debtor in the tort system or was actually submitted to a Debtor pursuant to an administrative settlement agreement. Date / / (ii) the date before the Commencement Date that the asbestos claim was filed against another defendant in the tort system if at the time the claim was subject to a tolling agreement with a Debtor. Date / / (iii) the date after the Commencement Date but before [the date that the PI Trust first makes available the proof of claim forms and other claims materials required to file a claim with the PI Trust] that the asbestos claim was filed against another defendant in the tort system. Date / / (iv) the date after the Commencement Date but before March 31, 2011 that a proof of claim was filed by the claimant against a Debtor in the Chapter 11 proceeding. Date / / (v) the date a ballot was submitted on behalf of the claimant for purposes of voting to accept or reject the Plan pursuant to the voting procedures approved by the Bankruptcy Court. Date / / Part 3B: OLD GM LITIGATION "Old GM" means Motors Liquidation Company (f/k/a General Motors Corporation; MLC of Harlem, Inc. (f/k/a Chevrolet-Saturn of Harlem, Inc.); MLCS, LLC (f/k/a Saturn, LLC); MLCS Distribution Corporation (f/k/a Saturn Distribution Corporation); Remediation and Liability Management Company, Inc.; and Environmental Corporate Remediation Company, Inc. and any entity for which one or more of these entities had liability. 1. Has an asbestos-related lawsuit ever been filed against Old GM on behalf of the injured party? Yes No a. State in which the suit was filed: b. Name of court in which the suit was originally filed: c. Case number: d. Date the suit was originally filed: / / (month) (day) (year) 5 of 15
7 e. If the suit resulted in any of the following, please check all that apply and provide the requested information. Settlement with Old GM: Date Amt Amt received to date: Judgment against Old GM: Date Amt Amt received to date: Jury verdict against Old GM: Date Amt Status: Dismissal of Old GM with prejudice: Date 2. If no suit was ever filed against Old GM, please elect one of the following and identify the jurisdiction: State of exposure to Old GM products: State of residence at time of filing (if Injured Party is living): State of residence at time of death (if Injured Party is deceased): State of residence at time of diagnosis: 3. Was a tolling agreement for the Injured Party ever in effect with respect to the claim(s) against Old GM? Yes No If Yes, please submit copy of tolling agreement. a. Date the tolling agreement began: (month) (day) (year) b. Date the tolling agreement ended: (month) (day) (year) 4. Has a claim been filed with Old GM pursuant to an administrative settlement agreement? Yes No If "Yes", please provide a copy of the administrative settlement agreement. a. Date the claim was originally filed: (month) (day) (year) b. Have you received money from Old GM for this claim? Yes No Part 3C: NEW GM LITIGATION LLITIGATION "New GM" means General Motors Company (formerly known as General Motors Holding Company), a Delaware corporation formed as part of that certain holding company reorganization that occurred on October 19, 2009, pursuant to which all of the outstanding shares of common stock and preferred stock of the prior General Motors Company (now known as General Motors LLC ) were exchanged on a one-forone basis for shares of common stock and preferred stock of the newly organized holding company that now bears the name General Motors Company. 1. Has the claimant received payment from New GM in satisfaction of a judgment entered in the tort system with respect to the Injured Party's asbestos personal injury claim? Yes No 2. Has the claimant filed suit against New GM with respect to the Injured Party's asbestos personal injury claim? Yes No 6 of 15
8 Part 4: OCCUPATIONAL EXPOSURE If claim is for Secondary Exposure, DO NOT complete Part 4, proceed to Part 5. See the TDP for exposure evidence necessary to meet the requirements for a valid and compensable claim. Pursuant to TDP Section 5.7(b)(3), claimants must demonstrate meaningful and credible exposure, which occurred prior to December 31, 1982, to asbestos or asbestos-containing products supplied, specified, manufactured, installed, maintained, or repaired by a Old GM and/or any entity 1, including an Old GM contracting unit, for which Old GM has legal responsibility ( Old GM Exposure ). Meaningful and credible exposure evidence may be established by an affidavit or sworn statement of the claimant, by an affidavit or sworn statement of a co-worker or the affidavit or sworn statement of a family member in the case of a deceased claimant (providing the PI Trust finds such evidence reasonably reliable), by invoices, employment, construction or similar records, or by other credible evidence. Claimants alleging Disease Levels VI (Lung Cancer I), IV (Other Cancer), III (Severe Asbestosis), II (Asbestosis/Pleural Disease), or I (Asbestosis/Pleural Disease I) must demonstrate at least six (6) months of Old GM exposure prior to December 31, Please photocopy this section and list separately each employment site, industry, product and occupation combination upon which you rely to meet the exposure requirements of the TDP. 4.1 Old GM Asbestos Exposure. Every claimant must submit evidence of exposure to Old GM asbestos products or activities. Employer: City: State: Site/Location of Alleged Exposure: City: State: Date employment began: / / Date employment ended: / / Date exposure began: / / Date exposure ended: / / Profession/Job Description: Describe exposure to Old GM asbestos- containing product(s) including the identity of the product(s): Attach all documents necessary to meet the meaningful and credible evidence of exposure requirements of the TDP. 1 Old GM means Motors Liquidation Company (f/k/a General Motors Corporation; MLC of Harlem, Inc. (f/k/a Chevrolet-Saturn of Harlem, Inc.); MLCS, LLC (f/k/a Saturn, LLC); MLCS Distribution Corporation (f/k/a Saturn Distribution Corporation); Remediation and Liability Management Company, Inc.; and Environmental Corporate Remediation Company, Inc. 7 of 15
9 4.2 Significant Occupational Exposure (SOE) for Claims other than Mesothelioma (Level VII) Claims, Lung Cancer 2 (Level V) Claims and Asbestos/Pleural Disease (Level I) Claims. [Please check all applicable statements.] Employment for a cumulative period of at least five (5) years with a minimum of two (2) years prior to December 31, 1982 in an industry and an occupation in which the Injured Party: Handled raw asbestos fibers on a regular basis; Fabricated asbestos-containing products so that the Injured Party in the fabrication process was exposed on a regular basis to raw asbestos fibers; Altered, repaired or otherwise worked with an asbestos-containing product such that the Injured Party was exposed on a regular basis to asbestos fibers; or Was employed in an industry and occupation such that the Injured Party worked on a regular basis in close proximity to workers engaged in the activities described in the preceding categories. If none of the above apply, provide a narrative description of how the claimant was occupationally exposed to asbestos at each site. If exposure information provided in 4.1 above is not sufficient to meet the SOE requirements, please provide additional occupational exposure information below. Employer: City: State: Site/Location of Alleged Exposure: City: State: Date employment began: / / Date employment ended: / / Date exposure began: / / Date exposure ended: / / Profession/Job Description: Describe exposure to asbestos- containing product(s) including the identity of the product(s): 8 of 15
10 Part 5: EXPOSURE THROUGH OCCUPATIONALLY EXPOSED PERSON Complete this part only if the Injured Party s asbestos-related disease is a result of asbestos exposure through an Occupationally Exposed Person ( OEP ). 2 Provide the following for each OEP claimed. Copy this page if more than one OEP is claimed. 5.1 Injured Party s Exposure Through OEP: The Injured Party had asbestos exposure on a regular basis through the OEP identified in 5.2 below From: / / To: / / Injured Party s Relationship to OEP: Describe the Injured Party s asbestos exposure through the OEP that is alleged to be the cause of the Injured Party s asbestos-related disease: Attach work history for the occupationally exposed person to establish meaningful and credible Debtor Exposure, prior to December 31, 1982, and Significant Occupational Exposure to asbestos, as applicable. 5.2 OEP s Debtor Asbestos Exposure: [For each additional exposure period, please copy this page and attach the additional completed information in this section.] Name of OEP: [First Name] [Middle Name] [Last Name] SSN: : - - Employer: City: State: Profession: Attach work history for the occupationally exposed person to establish meaningful and credible Old GM Exposure, prior to December 31, 1982, and Significant Occupational Exposure to asbestos, as applicable. 2 If the Injured Party claims direct occupational exposure to asbestos as well as exposure to an OEP, complete Part 4: OCCUPATIONAL EXPOSURE and Part 5: EXPOSURE THROUGH OCCUPATIONALLY EXPOSED PERSON. 9 of 15
11 5.3 OEP s Significant Occupational Exposure: for Claims other than Mesothelioma (Level VII) Claims, Lung Cancer 2 (Level V) Claims and Asbestos/Pleural Disease (Level I) Claims. [Please check all applicable statements.] Employment for a cumulative period of at least five (5) years with a minimum of two (2) years prior to December 31, 1982 in an industry and an occupation in which the OEP: Handled raw asbestos fibers on a regular basis; Fabricated asbestos-containing products so that the OEP in the fabrication process was exposed on a regular basis to raw asbestos fibers; Altered, repaired or otherwise worked with an asbestos-containing product such that the OEP was exposed on a regular basis to asbestos fibers; or Was employed in an industry and occupation such that the OEP worked on a regular basis in close proximity to workers engaged in the activities described in the preceding categories. If none of the above apply, provide a narrative description of how the claimant was occupationally exposed to asbestos at each site. Employer: City: State: Site/Location of Alleged Exposure: City: State: Date employment began: / / Date employment ended: / / Date exposure began: / / Date exposure ended: / / Profession/Job Description: Describe exposure to asbestos- containing product(s) including the identity of the product(s): 10 of 15
12 Part 6: Financial Dependents and Beneficiaries This must be completed for IR claims only 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. If additional space is required, please photocopy this page and insert after current page. 1. Name: (Last) (First) (MI) 2. Date of Birth: / / (month) (day) (year) 3. Relationship: Spouse 4. Financially Dependent: Yes Child Heir Other No 1. Name: (Last) (First) (MI) 2. Date of Birth: / / (month) (day) (year) 3. Relationship: Spouse 4. Financially Dependent: Yes Child Heir Other No 11 of 15
13 1. Name: (Last) (First) (MI) 2. Date of Birth: / / (month) (day) (year) 3. Relationship: Spouse 4. Financially Dependent: Yes Child Heir Other No 1. Name: (Last) (First) (MI) 2. Date of Birth: / / (month) (day) (year) 3. Relationship: Spouse 4. Financially Dependent: Yes Child Heir Other No 12 of 15
14 Part 7: Smoking History This must be completed for Lung Cancer 2 (LC2) and IR levels I through IV only 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 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) 13 of 15
15 Part 8: Employment Information for Economic Loss This is to be completed for IR claims only 1. Current Employment Status of the injured party: Full-time, outside the home Full-time, within the home Part-time, outside the home Part-time, within the home Retired Disabled Deceased 2. Amount of last annual wages: $ 3. Date of last wage received: / (month) (year) (Enter current date if currently earning work-related compensation.) If economic losses are being claimed, you must enclose an economic report, IRS Form W-2, the first page of IRS Form 1040, or other relevant supporting documentation. 14 of 15
16 Part 9: PROOF OF EXPOSURE Proof of exposure may be demonstrated by one or more of the following: The Injured Party, Attorney or Official Representative may demonstrate proof of exposure by completing Part 10: CERTIFICATION of this claim form, allowing the claim form to serve as the declaration. One or more of the following documents may be submitted to supplement credibility as to proof of exposure. The documents should be submitted as an attachment to the Claim Form and Part 10: CERTIFICATION section of this claim form must be signed. OR Affidavit or sworn statement of the claimant Affidavit or sworn statement of a co-worker or family member in the case of a deceased claimant (provided the Trust finds such evidence reasonably reliable) Invoices, employment, construction or similar records Other Evidence Verified Listing of employer/jobsites Verified Work History Answers to Claimant Interrogatories with verification page. Deposition Transcript with cover page(s) Part 10: CERTIFICATION Part 10: CERTIFICATION must be completed. This claim is certified by (check one) Attorney Injured Party Personal Representative I have reviewed the information submitted on this claim form and all documents submitted in support of this claim. Upon information and belief, under penalty of perjury, the information submitted is accurate and complete in all material respects. Signature of the Injured Party, Attorney or Personal Representative Printed name Date 15 of 15