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COMBUSTION ENGINEERING 524(g) ASBESTOS PI TRUST PROOF OF CLAIM FORM - PDF
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1 COMBUSTION ENGINEERING 524(g) ASBESTOS PI TRUST PROOF OF CLAIM FORM Submit completed claims to: Combustion Engineering 524(g) Asbestos PI Trust 2000 Lenox Drive, Suite 206 Lawrenceville, NJ [or if submitting claims electronically, go to https://trust.verusllc.com] Instructions for the Claim Form Complete this Claim Form as thoroughly and accurately as possible. For more detailed instructions please see the Instructions for Filing a Claim with the Combustion Engineering 524(g) Asbestos PI Trust (the CE Instructional Letter ) accompanying this Claim Form. Please type or print neatly. Should there be insufficient space to list all relevant information, please attach additional sheets. All references herein to the Trust shall refer to the Combustion Engineering 524(g) Asbestos PI Trust, references to CE shall refer to Combustion Engineering, Inc., and references to the CE TDP shall refer to the Combustion Engineering 524(g) Asbestos PI Trust Distribution Procedures. In addition to filing the forms that follow, please ensure the following are enclosed: Death Certificate (if applicable) Certificate of Official Capacity or other documentation complying with applicable state law (if Claim Form is filed by person other than the Injured Party) Medical records as requested in instructions Proof of CE product exposure as set out in the instructions Copy of cover sheet(s) of complaint or other proof of filing, signed release and tolling agreement (if applicable see Part 10 below) Proof of economic loss (if applicable see Part 13 below) Executed release (if applicable see Part 1 below) LEGAL REPRESENTATION (if applicable) If counsel represents claimant, print or type the following information: Attorney Last Name First Name MI Name of Law Firm Street / PO Box / Suite City State Zip Code - Attorney Phone No... Attorney Address Attorney Fax No...
2 Combustion Engineering Claim Form Page 2 Part 1: Choice of Claim Process Please choose the applicable claim process (choose only one): (The claim processes are described in the CE TDP as noted below.) Note: Claims for Lung Cancer 2 (Disease Level VI) must undergo the Individual Review claim process. If the claimant chooses Expedited Review the claimant must choose between either (i) Expedited Review with pre-acceptance of the claim settlement offer and submission of an executed release or (ii) Expedited Review without pre-acceptance of a claim settlement offer. (See CE Instructional Letter). Expedited Review with pre-acceptance of claim settlement offer. Executed release must be submitted with Claim Form (see Section 5.3 (a) of the CE TDP) Expedited Review without pre-acceptance of claim settlement offer (see Section 5.3 (a) of the CE TDP) Individual Review (see Section 5.3 (b) of the CE TDP) Part 2: Special Claim Status If you believe your claim qualifies as an Extraordinary Claim and/or an Exigent Hardship Claim as those terms are defined in Sections 5.4 (a) and 5.4 (b) of the CE TDP, respectively, check the appropriate box(es) indicating this and attach a separate sheet with a brief explanation and/or documentation in support thereof as required by the CE TDP. Note: Any person asserting that the claim qualifies as an Exigent Hardship Claim must certify to the Trust the aggregate amount the person has recovered in respect of the claim from other asbestos defendants and other asbestos claims resolution organizations. Extraordinary Claim (not available for Disease Levels I, II, or III) Exigent Hardship Claim (not available for Disease Levels I, II, or III) Part 3: Injured Party Information Last Name First Name MI Date of Birth / / Date of Death / / Was Death Asbestos Related? (Y / N) (If Yes, Death Certificate must be enclosed) Social Security No. - - Gender (M / F) Part 4: Claimant Information (if different than Injured Party) Last Name First Name MI Social Security No. - - Relationship to Injured Party (choose one): (Certificate of Official Capacity, other documentation complying with applicable state law, or certification in Part 16, below, must be provided) Executor/Administrator/Trustee Power of Attorney Guardian Other
3 Combustion Engineering Claim Form Page 3 Part 5: Mailing Address of Claimant (required if not represented by counsel) Street / PO Box / Apt. # City State Zip Code - Phone No. (daytime).. Phone No. (evening).. Part 6: Diagnosed Asbestos-Related Injuries Place an X next to the highest Disease Level (by number) that has been diagnosed for the Injured Party for which medical documentation is available. Please see Section 5.3(a)(3) of the CE TDP for a listing of the specific medical criteria and records that are required for each Disease Level. Mesothelioma (Level VIII) Lung Cancer 1 (Level VII) Lung Cancer 2 (Level VI) Note: Claims for Lung Cancer 2 (Level VI) must undergo the Individual Review claim process. Other Cancer (Level V) (e.g., Colo-rectal, Laryngeal, Esophageal, Pharyngeal, Stomach Cancer) Severe Asbestosis (Level IV) Asbestosis/Pleural Disease (Level III) Asbestosis/Pleural Disease (Level II) Other Asbestos Disease (Level I Cash Discount Payment) Date of Diagnosis / / Date of Diagnosis / / Date of Diagnosis / / Date of Diagnosis / / The claims must meet the relevant medical criteria as delineated in the CE TDP. In order to expedite the processing of claims and minimize the expense of claims processing, with the consent of the claimant, the Trust will use the results of previous reviews of medical records for other asbestos defendants in the possession of Verus Claims Services, LLC ( Verus ) for the verification of the claimed medical condition. Notwithstanding the foregoing, the Trust maintains the right to request medical documentation for all individual claims. A. Use results of previous medical reviews if available. Yes No B. Do not use results of previous medical reviews. Required medical records are enclosed. Yes No
4 Combustion Engineering Claim Form Page 4 Part 7: Occupational Exposure Complete this Part to demonstrate the necessary CE Exposure, Significant Occupational Exposure and/or five years cumulative occupational exposure as required by the CE TDP for the Disease Level claimed. Please see the CE Instructional Letter for the presumptive exposure requirements for Expedited Review. If the claimant cannot meet the relevant presumptive exposure requirements for a Disease Level eligible for Expedited Review, the claimant may seek Individual Review of the claim. Please photocopy Part 7 of this Claim Form and list separately each site, industry or occupation upon which claimant relies to establish the necessary exposure. A. CE EXPOSURE: (see Section 5.7(b)(3) of the CE TDP for CE Exposure evidentiary requirements) Complete this subpart A to satisfy the CE Exposure requirement and, if applicable to the Disease Level claimed, to satisfy the Significant Occupational Exposure or five years cumulative occupational exposure requirements. If the claim is for a Disease Level for which Significant Occupational Exposure or five years cumulative occupational exposure is required, but the Injured Party s exposure to asbestos for which CE is legally responsible does not satisfy the applicable requirements, subpart B must also be completed. This subpart A relates only to CE Exposure. Subpart B relates to exposure to any asbestos other than asbestos for which CE is legally responsible. 1. Name of Plant/Site/Ship or Vessel of CE Exposure: City: State: 2. Month/Year CE Exposure Began: / Month/Year CE Exposure Ended: / 3. Occupation at time of CE Exposure: (see Occupation Codes listed in the CE Instructional Letter.) If Occupation Code 60 (other) is designated, specify the other occupation: 4. Industry in which CE Exposure occurred: (see Industry Codes listed in the CE Instructional Letter.) If code OT (other) is designated, specify the other industry: 5. Indicate the circumstances of CE Exposure by checking all applicable statements: a. Injured Party handled raw asbestos fibers on a regular basis; or b. 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; or c. Injured Party altered, repaired or otherwise worked with an asbestos-containing product such that the Injured Party was exposed on a regular basis to raw asbestos fibers; or d. Injured Party was employed in an industry and occupation such that the Injured Party worked on a regular basis in close proximity to workers engaged in one or more of the activities described in (a), (b) and/or (c).
5 Combustion Engineering Claim Form Page 5 e. Other. Briefly describe the circumstances of the Injured Party s CE Exposure. 6. If this exposure is in support of Exposure to an Occupationally Exposed Person from Part 8, please provide the name and social security number of the occupationally exposed individual: - - (Last Name) (First Name) (M.I.) (Social Security #) B. SIGNIFICANT OCCUPATIONAL EXPOSURE / FIVE YEARS CUMULATIVE OCCUPATIONAL ASBESTOS EXPOSURE: (see Section 5.7(b)(2) of the CE TDP for Significant Occupational Exposure evidentiary requirements) Complete this subpart B only if (i) the claim is for a Disease Level that requires Significant Occupational Exposure (Disease Levels III, IV, V or VII) or five years cumulative occupational asbestos exposure (Disease Level II); and (ii) the responses to subpart A above do not satisfy the applicable requirements. This subpart B relates to exposure to any asbestos other than asbestos for which CE is legally responsible. (Please photocopy and use a separate page for each job site). 1. Name of Plant/Site/Ship or Vessel of Exposure: City: State: 2. Month/Year Exposure Began: / Month/Year Exposure Ended: / 3. Occupation at time of exposure: (see Occupation Codes listed in the CE Instructional Letter.) If Occupation Code 60 (other) is designated, specify the other occupation: 4. Industry in which exposure occurred: (see Industry Codes listed in the CE Instructional Letter.) If code OT (other) is designated, specify the other industry: 5. Indicate the circumstances of the exposure by checking all applicable statements: a. Injured Party handled raw asbestos fibers on a regular basis; or b. 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; or c. Injured Party altered, repaired or otherwise worked with an asbestos-containing product such that the Injured Party was exposed on a regular basis to raw asbestos fibers; or
6 Combustion Engineering Claim Form Page 6 d. Injured Party was employed in an industry and occupation such that the Injured Party worked on a regular basis in close proximity to workers engaged in one or more of the activities described in (a), (b) and/or (c). e. Other. Briefly describe the circumstances of the exposure. Part 8: Exposure to an Occupationally Exposed Person 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, brother, sister, etc.)? Yes No If No, proceed to Part 9. If Yes, you must complete Part 7 for each occupationally exposed person claimed and complete the following. Claimants alleging an asbestos-related disease resulting in whole or in part from exposure to an occupationally exposed person, such as a family member, must establish that the occupationally exposed person would have met the exposure requirements under the CE TDP that would have been applicable had that person filed a direct claim against the Trust. Complete the following for each occupationally exposed person claimed. (If claimant alleges an asbestosrelated disease resulting from more than one occupationally exposed person, please photocopy this Part and provide the information for each occupationally exposed person claimed.) 1. Date exposure from other person began: / (Month) (Year) 2. Date exposure from other person ended: / (Month) (Year) 3. Relationship to occupationally exposed individual: Injured Party is/was the of the occupationally exposed individual. (spouse, parent, brother, sister, etc.) 4. Describe how the Injured Party was exposed to the CE product:
7 Combustion Engineering Claim Form Page 7 5. Provide the name and social security number of the occupationally exposed individual: - - (Last Name) (First Name) (M.I.) (Social Security #) Reminder: Part 7 must be completed for the occupationally exposed person. If the Injured Party also had direct, occupational exposure to asbestos, Part 7 must also be completed for that exposure. Part 9: Proof of Exposure The claimant must sign Part 16 of this Claim Form or attach one or more of the following documents checked below as Proof of Exposure. An affidavit of the claimant An affidavit of a co-worker An affidavit of a family member in the case of a deceased claimant Invoices, employment, construction or similar records Verified listing of employer/jobsites Verified work history Answers to interrogatories with verification page. Specify pertinent page number(s). Deposition transcript with cover page(s). Specify pertinent page number(s). Other.
8 Combustion Engineering Claim Form Page 8 Part 10: Statute of Limitations and Claims History 1. Has an asbestos-related lawsuit been filed on behalf of the Injured Party against any asbestos defendant? Yes No (If Yes, a photocopy of the cover sheet(s) of the complaint or other proof of filing must be enclosed. Please see the CE Instructional Letter for other proof of filing requirements.) a. Date the suit was originally filed: / / b. State in which the suit was originally filed: c. Name of court in which the suit was originally filed: d. Case number: e. Was Combustion Engineering, Inc. named in the suit? Yes No f. Has the claimant ever received money for an asbestos-related injury or asbestos claim from Combustion Engineering, Inc. or the CE Settlement Trust? Yes No If Yes, a copy of the signed Release must be enclosed. If the Release is not available, provide the following information, if known, that may assist to locate the document: Name of Claimant s Attorney: Name of Claimant s Defense Counsel: For Questions 2 and 3, below, you must provide the following information unless counsel for the claimant has previously submitted this information to the Trust. 2. Has a claim on behalf of the Injured Party ever been submitted to Combustion Engineering, Inc. pursuant to an administrative settlement agreement (an agreement to settle that was reached without filing a lawsuit)? Yes No If Yes, provide the date of such submission: / / 3. Was the Injured Party or claimant a party to a tolling agreement (an agreement that extends the deadline for filing a lawsuit) with Combustion Engineering, Inc.? Yes No If Yes, provide the beginning and ending dates, if any, of the tolling and attach documentation of the agreement. Beginning Date: / / Ending Date: / /
9 Combustion Engineering Claim Form Page 9 Part 11: Smoking History NOTE: This information is relevant to all claims involving Lung Cancer 1 (Disease Level VII) and claims involving Lung Cancer 2 (Disease Level VI). Thus, this section does not need to be completed if your claim is for Disease Levels I, II, III, IV, V, or VIII. For each item, indicate whether the Injured Party has smoked or used the given product. If cigarettes were smoked, indicate the dates they 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. Has the Injured Party ever smoked cigarettes? Yes No From / To / Packs per day:. (Month) (Year) (Month) (Year) From / To / Packs per day:. (Month) (Year) (Month) (Year) From / To / Packs per day:. (Month) (Year) (Month) (Year) Has the Injured Party ever smoked cigars? Yes No From / To / Cigars per day:. (Month) (Year) (Month) (Year) From / To / Cigars per day:. (Month) (Year) (Month) (Year) From / To / Cigars per day:. (Month) (Year) (Month) (Year)
10 Combustion Engineering Claim Form Page 10 INDIVIDUAL REVIEW OF CLAIMS If claimant is requesting Individual Review, please see the CE Instructional Letter for further information regarding the Individual Review process. IF CLAIMANT IS NOT REQUESTING INDIVIDUAL REVIEW, PROCEED TO PART 16 OF THE CLAIM FORM. IF INDIVIDUAL REVIEW IS REQUESTED, PARTS 12, 13, 14 AND 15 OF THE CLAIM FORM MUST BE COMPLETED TO THE EXTENT APPLICABLE. Part 12: Financial Dependents and Beneficiaries NOTE: The following information must be provided if the claimant is requesting Individual Review. 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 the Injured Party s death) at least one-half of their financial support from the Injured Party. Also, list beneficiaries who are entitled to pursue an action for wrongful death under applicable state law. If additional space is required, please photocopy this page and insert after current page. Last Name First Name MI Date of Birth / / Relationship to Injured Party Financially Dependent: Yes No Last Name First Name MI Date of Birth / / Relationship to Injured Party Financially Dependent: Yes No Last Name First Name MI Date of Birth / / Relationship to Injured Party Financially Dependent: Yes No
11 Combustion Engineering Claim Form Page 11 NOTE: Complete for Individual Review. Part 13: Employment Information for Economic Loss 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 Amount of last annual wages: $,. Date of last wage received: / (Month) (Year) (Enter current month and year if currently earning work-related compensation) If economic losses are being claimed, you must enclose supporting documentation to prove economic losses which may include medical bills, a forensic economic report, IRS Form W-2, the first page of IRS Form 1040, or other relevant supporting documentation. Economic loss may include disruption of household, family or recreational activities.
12 Combustion Engineering Claim Form Page 12 Part 14: Claimant s Jurisdiction NOTE: The following information must be provided if the claimant is requesting Individual Review and the claimant did not file a claim for an asbestos-related injury against CE in the tort system prior to February 17, Please see the CE Instructional Letter for further information concerning the Claimant s Jurisdiction. If the claimant did not file a claim for an asbestos-related injury against CE in the tort system prior to February 17, 2003, please provide the state and country which the claimant elects as the Claimant s Jurisdiction:. (See Instructional Letter, page 5, for an explanation of the choices). The Claimant s Jurisdiction elected is (please check one of the following): The state in which the claimant resided at the time of diagnosis. The state in which the claimant resides when this claim is filed with the Trust. The state in which the claimant experienced CE Exposure. Part 15: Other Valuation Factors to be Considered for Individual Review To the extent claimant believes there are other valuation factors that the Trust should consider in evaluating this claim under the Individual Review process as provided in Section 5.3(b) of the CE TDP, which factors are not otherwise provided in this Claim Form, please attach a separate, written explanation, not to exceed three (3) pages in length, describing the factors and explaining why the Trust should take the factors into consideration in evaluating this claim. Please attach any applicable case or statutory law to support consideration of these other factors.
13 Combustion Engineering Claim Form Page 13 Part 16: Signature Page All claims must be signed by the Injured Party, or the person filing on the Injured Party s behalf (such as an authorized representative or attorney.) If signed by the Injured Party or a person authorized by state law to file the claim on behalf of the Injured Party, I (the claimant) have reviewed the information submitted on this Claim Form and all documents submitted in support of this claim. I intend that the information submitted on this Claim Form be considered as evidence of exposure to asbestos or asbestos-containing products for which Combustion Engineering, Inc. has legal responsibility. I declare under penalty of perjury under the laws of the United States of America that all of the information submitted is accurate and complete and I (the claimant) have not previously relinquished my rights to such a claim against Combustion Engineering, Inc. or against the Combustion Engineering 524(g) Asbestos PI Trust. If signed by claimant s counsel, I (counsel to the Injured Party or authorized representative) certify that the information and materials with respect to this claim are being submitted pursuant to and subject to the provisions of Rule 11 of the Federal Rules of Civil Procedure. In the event that the claim is filed by a person authorized under state law to file a claim on behalf of the Injured Party and a Certificate of Official Capacity or other estate documentation as may be applicable per state law is not submitted with this Claim Form, I further certify that this claim is filed on behalf of the Injured Party by a person authorized under state law to file this claim on behalf of the Injured Party. Executed on this day of, 20 Signature of claimant, personal representative, or claimant s counsel Please print the name and relationship to the claimant of the signatory above Please review your submission to ensure it is complete. Death Certificate (if applicable) Certificate of Official Capacity or other documentation complying with applicable state law (if Claim Form is filed by person other than the Injured Party) (if applicable) Executed release (if applicable under Part 1) Medical records as required by the CE TDP and as requested in the instructions Proof of Combustion Engineering, Inc. product exposure as required in the CE TDP and as requested in the instructions Copy of cover sheet(s) of complaint or other proof of filing, signed release and tolling agreement (if applicable under Part 10) Proof of economic loss (if Part 13 is applicable)