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CLAIM FORM & CERTIFICATION FOR LESLIE CONTROLS, INC. ASBESTOS PERSONAL INJURY TRUST - PDF
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1 Submit claims to: Website- lesliecontrolsasbestostrust.com Or - Or Mail to- Leslie Controls, Inc. Asbestos Personal Injury 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 Leslie Controls, Inc. Asbestos Personal Injury Trust and the Leslie Controls, Inc. Asbestos Personal Injury Trust Distribution Procedures (the TDP ).
2 Part 1: INJURED PARTY and CLAIM INFORMATION 1.1 Claim Type: Leslie Powerhouse and Below-Deck Naval Station Claim Check all that apply: The Injured Party performed or was in the immediate vicinity of a worker who performed: installation, maintenance or removal of Leslie valves installation, maintenance or removal of other control equipment manufactured by Leslie identified as: which occurred while the Injured Party was: regularly employed in a Leslie Powerhouse; identify the Leslie Powerhouse(s): in a United States shipyard while working on naval vessels; identify the shipyard(s) and/or vessel(s): serving at an assigned Below-Deck Naval Station; identify the Below-Deck Naval Station(s): other (please specify): Leslie Construction and Maintenance Claims 1.2 Injured Party s Full Name: [First Name] [Middle Name] [Last Name] SSN: - - Date of Birth: / / Month Day Year Gender: M F 1.3 Is the Injured Party Living? Yes No If No, provide the following: Date of Death: / / Month Day Year Official Representative s Full Name: [First Name] [Middle Name] [Last Name] Also provide Death Certificate and one of the Following: Certificate of Official Capacity Other applicable document authorizing a person to act on behalf of the Injured Party Official Representative Certification (below) signed by Attorney 1 of 14
3 Official Representative Certification This certification eliminates the need for any documentation of authority on behalf of a deceased claimant. Attorney certifies that this claim is filed on behalf of the Official Representative acting for the Injured Party and that the Official Representative has official capacity to file this claim based on the operation of law. Signature of Attorney Printed Name 1.4 Injured Party s Law Firm Contact Information Firm Name: Attorney Name: Phone Number: Para/Admin Name: Phone Number: Address: Address: 1.5 Review of claim: (a) Expedited and Individual Review: Please check the appropriate box: Expedited Review Individual Review (In addition, complete Part 7 of this Claim Form) (b) Please check the box(es) for any of the following features that apply: Secondary Exposure Claim Extraordinary Claim Exigent Health Claim Exigent Hardship Claim Foreign Claim 2 of 14
4 1.6 Has the Injured Party ever received money for an asbestos-related injury or claim from Leslie Controls, Inc.? Yes No 1.7 Has the Injured Party ever entered into a release of Leslie Controls, Inc. for an asbestos-related injury or claim? If yes, provide a copy of the release. Yes No 3 of 14
5 Part 2: DIAGNOSED DISEASES 2.1 DISEASE CLAIMED Check the box indicating the highest disease level claimed by the Injured Party for which there is attached medical evidence to support the claim. Provide the date of first diagnosis for the disease claimed. See Instructions for Filing a Claim With the Leslie Controls, Inc. Asbestos Personal Injury 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 Disease Level VI Lung Cancer 1 Disease Level VII Mesothelioma 4 of 14
6 2.2 Has the Injured Party been diagnosed with a Scheduled Disease other than the diagnosis identified above? This request excludes medical or legal evaluations by purely consulting experts that are protected by a privilege under applicable state law that has not been waived. Yes No If the answer is Yes, please provide a copy of the report that makes the diagnosis, even if it was made by one of the unacceptable doctors or medical facilities listed in the Instructions. Please check this box if the Injured Party or Claimant filed a claim against Leslie Controls, Inc. or any other asbestos defendant in the tort system before July 12, 2010 and filed a physical examination report with another asbestos-related personal injury settlement trust or has available such a report by an examining physician engaged by the claimant or his or her law firm. 5 of 14
7 Part 3: STATUTE OF LIMITATIONS 3.1 In which state does the Injured Party currently reside or, if deceased, in which state did the Injured Party reside at time of death? 3.2 Does a tolling agreement apply? Yes No If Yes, provide a copy of the tolling agreement. If an asbestos-related lawsuit has been filed against Leslie Controls, Inc. on behalf of the Injured Party, please provide the following: 3.3 Where was the lawsuit filed? City: County: State: Name of Court: 3.4 Date on which the lawsuit was originally filed: / / 3.5 Provide the Docket or Case Number of the lawsuit: 3.6 Was a final non-appealable judgment entered against Leslie Controls, Inc. in the lawsuit? Yes No 6 of 14
8 Part 4: LESLIE CONTROLS SPECIFIC OCCUPATIONAL EXPOSURE AND SIGNIFICANT OCCUPATIONAL EXPOSURE If claim is for Secondary Exposure, DO NOT complete Part 4, proceed to Part 5. Part 4 of this Claim Form must be completed if the Injured Party claims that his/her asbestos-related disease is a direct result of his/her occupational asbestos exposure. See the TDP for exposure evidence necessary to meet the requirements for a valid and compensable claim. Copy this page if exposure occurred at more than one site. 4.1 Leslie Controls Asbestos Exposure Employer: City: State: Site/Location of Alleged Exposure: City: State: Date employment began: / / Date employment ended: / / Profession/Job Description: Describe exposure to Leslie Controls asbestos-containing product: Identify Leslie Controls asbestos-containing product: Attach work history to establish meaningful and credible Leslie Controls Exposure prior to December 31, 1986, and Significant Occupational Exposure (SOE) to asbestos, as applicable. 7 of 14
9 4.2 Significant Occupational Exposure (SOE) for Claims other than Mesothelioma 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, 1986 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. -Attach Work History- (If Leslie Controls work history exposure does not meet SOE requirements) 8 of 14
10 Part 5: SECONDARY EXPOSURE: 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 ). 1 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: 5.2 OEP s Leslie Controls Asbestos Exposure [Copy this page if exposure occurred at more than one site.] Name of OEP: [First Name] [Middle Name] [Last Name] Employer: City: State: Site/Location of Alleged Exposure: City: State: Date employment began: / / Date employment ended: / / Profession/Job Description: Describe exposure to Leslie Controls asbestos-containing product: Identify Leslie Controls asbestos-containing product: 1 If the Injured Party claims direct occupational exposure to asbestos as well as exposure to an OEP, complete Part 4: LESLIE CONTROLS SPECIFIC OCCUPATIONAL EXPOSURE AND SIGNIFICANT OCCUPATIONAL EXPOSURE and Part 5: SECONDARY EXPOSURE: EXPOSURE THROUGH OCCUPATIONALLY EXPOSED PERSON. 9 of 14
11 Attach work history for the OEP to establish meaningful and credible Leslie Controls Exposure, prior to December 31, 1986, and Significant Occupational Exposure to asbestos, as applicable. 5.3 OEP s Significant Occupational Exposure for Claims other than Mesothelioma 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, 1986 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. -Attach Work History- (If Leslie Controls work history exposure does not meet SOE requirements) 10 of 14
12 Part 6: PROOF OF EXPOSURE Proof of exposure may be demonstrated by: The Injured Party or Official Representative may complete Part 8: CERTIFICATION of this claim form and check the box certifying that he or she is acting on personal knowledge, in which case the claim form shall serve as an Affidavit or Sworn Statement. OR The Attorney or Official Representative may complete Part 8: CERTIFICATION of this claim form and provide an affidavit or sworn statement on personal knowledge of a co-worker or of a family member in the case of a deceased claimant (provided the Trust finds such evidence reasonably reliable). For Leslie Powerhouse and Below-Deck Naval Station Claims, the following documentation also must be provided: Proof of military service or employer; AND Evidence of location of military service or employment; Satisfactory evidence of trade or job, such as employment application, invoices or employment, construction, military, union or similar records; and If the exposure is alleged to have occurred on a commercial vessel, independent corroborating documentary evidence of Leslie asbestoscontaining products. In addition, one or more of the following documents may be submitted to supplement credibility as to proof of exposure. Verified Listing of employer/jobsites Verified Work History Answers to Claimant Interrogatories with verification page Deposition Transcript with cover page(s) 11 of 14
13 Part 7: INDIVIDUAL REVIEW INFORMATION Complete this part only if Individual Review is elected. 7.1 Smoking History Cigarettes Cigars Pipes Cigarettes Cigars Pipes Cigarettes Cigars Pipes Start Date Start Date Start Date End Date End Date End Date Per Day (packs, cigars, pipes) Per Day (packs, cigars, pipes) Per Day (packs, cigars, pipes) 7.2 Economic Loss Wage Loss Employment Status (including Military Service) Full-time Part-time Retired Disabled Deceased Check the box if you have attached an economic loss report containing documentation of the following: Last annual wage and date employment ceased $ / / Other Economic loss Other Sources of Income and Living Expenses Pension Social Security Household Services Medical Expenses Funeral Expenses Check the box if you have attached an economic loss report containing documentation of the following: 12 of 14
14 7.3 Heirs Last name First name Middle name Date of Birth Relationship to Injured Party Financially Dependant Yes No Last name First name Middle name Date of Birth Relationship to Injured Party Financially Dependant Yes No Last name First name Middle name Date of Birth Relationship to Injured Party Financially Dependant Yes No Last name First name Middle name Date of Birth Relationship to Injured Party Financially Dependant Yes No 7.4 Foreign Claim Check here if the Injured Party was exposed to an asbestos-containing product for which Leslie Controls, Inc. has legal responsibility outside of the United States and its Territories and Possessions and outside the Provinces and Territories of Canada. 13 of 14
15 Part 8: CERTIFICATION This claim is certified by (check one and check capacity in which Certification is provided) Injured Party on personal knowledge Official Representative on personal knowledge affidavit or sworn statement attached Attorney (affidavit or sworn statement attached) I have reviewed the information submitted on this claim form and all documents submitted in support of this claim. To the best of my knowledge, under penalty of perjury, the information submitted is accurate and complete in all material respects. Signature of the Injured Party, Official Representative or Attorney Printed name 14 of 14