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FEDERAL-MOGUL ASBESTOS PERSONAL INJURY TRUST PROOF OF CLAIM FORM - PDF
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1 FEDERAL-MOGUL ASBESTOS PERSONAL INJURY TRUST Submit completed claims to: T&N Subfund of the Federal-Mogul Asbestos Personal Injury Trust P.O. Box 8401 Wilmington, DE Instructions for the Claim Form File your claim more efficiently. Submit and manage your claim electronically through the Federal-Mogul Asbestos Personal Injury Trust s (the Trust ) website. Visit for more information. 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 Personal Injury Trust Distribution Procedures ("TDP") and as requested in instructions Proof of T&N Entity Exposure as set out in the instructions Documentation of Economic Loss (if applicable see Part 8 below) Filing Against a T&N Subfund Entity: Please check whether the specific claim exposure being alleged is against T&N, Flexitallic, or Ferodo. CHECK ONLY ONE BOX BELOW. Multiple Exposure Claims against the T&N Subfund must be filed separately. For example, if you have claims for both T&N and Ferodo exposure, you must submit one complete claim form for T&N exposure and a separate complete claim form for Ferodo exposure. T&N Subfund: T&N Exposure Flexitallic Exposure Ferodo Exposure 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: v60 Page 1
2 4. Attorney Phone: ( ) Fax: ( ) 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. Is injured party living? Yes No 6. If injured party is deceased, please complete the following: (Death Certificate must be enclosed) 6a. Date of death: / / 6b. Was death asbestos-related? Yes No 7. If injured party is living and not represented by counsel, please complete the following: 7a. Mailing address: (street/po Box) (city/state/zip) 7b. Daytime Phone: ( ) - 7c. Address: 8. 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 available.) 8a. Name: (Last) (First) (MI) 8b. Social Security Number: - - Page 2
3 8c. Mailing Address: (street/po Box) (city/state/zip) 8d. Daytime Phone: ( ) - 8e. Address: 8f. Relationship to injured party: (spouse, child, etc.) Page 3
4 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 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 I (Primary lung cancer plus Bilateral Asbestos-Related Non-Malignant Disease) VI Lung Cancer 2 (Primary lung cancer) (Individual Review Only) V Other Cancer (Please specify: ) (Primary cancer other than lung cancer plus Bilateral Asbestos-Related Non-Malignant Disease) IV Severe Asbestosis (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%) 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 (Bilateral Asbestos-Related Non-Malignant Disease) (Cash Payment Discount, not subject to the Payment Percentage) 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 a T&N Entity or any other asbestos defendant in the tort system prior to the Petition Date, please check this box if you have filed a physical examination 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) Page 4
5 Part 3: T&N Entity or Other Asbestos Exposure and Significant Occupational Exposure Proof of T&N Entity exposure for the relevant entity and proof of Significant Occupational Exposure to all asbestosrelated products are addressed below and must be enclosed 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. Please include detail concerning all asbestos exposure (not just T&N Entity exposures) that you think is sufficient to meet the exposure criteria for approval of the claim at the claimed disease level. List each site, industry, and occupation combination separately. For T&N Entity exposures, a list of approved T&N Entity sites is available on the Trust website (www.federalmogulasbestostrust.com). Please reference this list and enter the Approved T&N Entity Site Code in item #1 below. If the site at which you are alleging exposure to the relevant T&N Entity's products or services is not on the relevant approved T&N Entity site list, provide independent documentation of meaningful and credible evidence of exposure to asbestos-containing products manufactured by the relevant T&N Entity or for which the relevant T&N Entity is liable. This may be established by documentation including, but not limited to, the following: - An affidavit of the injured party (an example is included in the filing instruction) - An affidavit of a co-worker - An affidavit of a family member in the case of a deceased claimant - Invoices - Construction or similar records (Part 3, continued) 1. Site/Plant/Ship where Exposure Occurred: If the site is on the relevant T&N Entity approved site list, enter the Site Code from Exhibit A (available on website): Approved Site Code (see Exhibit A): If the site/plant/ship is not on the approved list or is not an exposure to the relevant T&N Entity products or services, please complete the following: Name of Ship/Plant/Site of Exposure: City: State/Province: Country: Name of T&N Entity product(s), if applicable, to which the injured party is alleging exposure: Page 5
6 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 5. Significant Occupational Exposure (SOE) If your occupation does not appear on the list of Presumptive SOE Occupations Ratings (available at please advance directly to question 6. If it does appear on the list, indicate circumstances of exposure to asbestos products or activities (check all applicable): Claimant handled raw asbestos fibers on a regular basis Claimant fabricated asbestos-containing products such that the claimant in the fabrication process was exposed on a regular basis to raw asbestos fibers Claimant altered, repaired or otherwise worked with an asbestos-containing product such that the claimant was exposed on a regular basis to asbestos fibers Claimant was employed in an industry or occupation such that the claimant 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 claimant 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 claimant was exposed to asbestos at each relevant site. Page 6
7 7. Company Exposure Every claimant must submit evidence of exposure to relevant T&N Entity asbestos products or activities. a. To demonstrate exposure to T&N Entity 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. (check one box only) 1. The site in Question #1 is on the relevant T&N Entity 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 the relevant T&N Entity's asbestos products/activities; or 3. Claimant s answer to Question #1 otherwise identifies the relevant T&N Entity s asbestos products/activities at this site (e.g. coworker affidavit), and also identifies the injured party by name; or The answer to Question #1 provides evidence that the relevant T&N Entity 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; or None of the above apply. b. If the box 5 was checked, or if the 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 the relevant T&N Entity at this site: 8. If this exposure is in support of Exposure to an Occupationally Exposed Person from Part 4, 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 Sections 5.3(a)(2) and 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 Exposure to other person began: / (month) (year) 3. Date Exposure to other person ended: / (month) (year) 4. Relationship to occupationally exposed individual: (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 T&N Entity product: 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 the T&N Entity that is the subject of this claim (the "Relevant Entity ) named as a defendant? Yes No b. State in which the suit was originally filed: c. Name of court in which the suit was originally filed: d. Case number: e. Date the suit was originally filed: / / f. Have you received money from the Relevant Entity or on behalf of the Relevant Entity regarding this suit? Yes No g. Did you sign a release releasing the Relevant Entity regarding this suit? Yes No h. Have you filed a workmen s compensation claim against the Relevant Entity? Yes No 2. If the answer to question 1(a) above is No, in which state/jurisdiction would the claimant have elected to file suit against the Relevant Entity? (state) 3. Was a tolling agreement for the injured party ever in effect with respect to the claim(s) against the Relevant Entity? Yes No If Yes, please submit copy of tolling agreement. a. Date the tolling agreement began: / / b. Date the tolling agreement ended: / / 4. Has a claim been filed with the Relevant Entity pursuant to an administrative settlement agreement? Yes No a. Date the claim was originally filed: / / b. Have you received money from the Relevant Entity re: this claim? Yes No Page 9
10 Part 6: Financial Dependents and Beneficiaries 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 No Heir Other 1. Name: 2. Date of Birth: / / (Last) (First) (MI) 3. Relationship: Spouse 4. Financially Dependent: Yes Child No Heir Other 1. Name: 2. Date of Birth: / / (Last) (First) (MI) 3. Relationship: Spouse 4. Financially Dependent: Yes Child No Heir Other 1. Name: 2. Date of Birth: / / (Last) (First) (MI) 3. Relationship: Spouse 4. Financially Dependent: Yes Child No Heir Other Page 10
11 Part 7: Smoking History FEDERAL-MOGUL ASBESTOS PERSONAL INJURY TRUST 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 I through IV 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 FEDERAL-MOGUL ASBESTOS PERSONAL INJURY TRUST 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 T&N Entity Exposure and Significant Occupational Exposure as required in the TDP and requested in the instructions, including affidavits 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) 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