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Instructions For Filing a Claim With Leslie Controls, Inc. Asbestos Personal Injury Trust - PDF Free Download
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1 Instructions For Filing a Claim With The CLAIM FORM & CERTIFICATION FOR LESLIE CONTROLS, INC. ASBESTOS PERSONAL INJURY TRUST (the Claim Form ) is required of all persons filing a claim with the LESLIE CONTROLS, INC. ASBESTOS PERSONAL INJURY TRUST (the Trust ) as or on behalf of an injured party (the Injured Party ). These instructions are intended to summarize certain significant issues related to filing a personal injury claim with the Trust. Nothing in these instructions is intended to replace or modify the requirements of the Distribution Procedures (the "TDP"). All claimants are encouraged to thoroughly read and understand the TDP (available on the Trust s website) before filing a claim with the Trust. Capitalized terms used but not defined in these Instructions shall have the meanings assigned in the TDP or the Second Conformed First Amended Plan of Reorganization of Leslie Controls, Inc. Under Chapter 11 of the Bankruptcy Code. How to Qualify for a Settlement Offer: To submit a valid personal injury claim, a claimant must provide: A completed Claim Form; A medical diagnosis of a compensable disease and supporting documentation as required by the TDP and set forth in the Claim Form; Evidence of exposure to a Leslie Controls product with the dates of commencement and termination of such exposure; and Any other applicable documentation required by the TDP and set forth in the Claim Form. A claimant must submit a fully completed Claim Form and provide all supporting documentation referenced in the form. Failure to submit a fully completed Claim Form will result in submission or processing delays. A Claim Form that does not include information in all required fields will be deemed deficient and remain deficient until the claimant answers all necessary questions on the Claim Form. Please type or print responses on the Claim Form. If you need additional space to provide all relevant information, please attach additional sheets. Claim Form Part 1: INJURED PARTY AND CLAIM INFORMATION 1.1: Check the appropriate boxes. See Sections 5.2(i) and 5.2(ii) of the TDP for definitions of Leslie Powerhouse and Below-Deck Naval Station Claims and Leslie Construction and Maintenance Claims. 1.2: Provide the full name, social security number, date of birth and gender of the Injured Party for whom the claim is being filed. 1.3: Check the appropriate box indicating whether the Injured Party is living. If the Injured Party is deceased, provide the date of death and full name of the Injured Party s official representative (the Official Representative ). Additionally, provide a copy of the death certificate and one of the following: Certificate of Official Capacity Other applicable document authorizing a person to act of behalf of the Injured Party Official Representative Certification (signed by Attorney) 1
2 Instructions For Filing a Claim With 1.4: Provide the claimant s law firm contact information, including firm name, attorney name and phone number, paralegal/administrative assistant name and phone number, address and : Check the appropriate box(es). See Sections 5.2, 5.3 and 5.4 of the TDP for descriptions of types of claims review and claims. 1.6: Check the box indicating whether the Injured Party ever received money for an asbestos-related injury or claim from 1.7: Check the box indicating whether the Injured Party ever entered into a release of Leslie Controls, Inc. for an asbestos-related injury or claim. Provide a copy of the release, if applicable. Claim Form Part 2: DIAGNOSED DISEASES Check only the box identifying the highest Disease Level claimed by the claimant and provide the date of first diagnosis for the Disease Level claimed. Section 5.2 of the TDP states: The proof of claim form shall require a claimant to assert his or her claim for the highest Disease Level for which the claim qualifies at the time of filing. Without regard to the Disease Level alleged on the proof of claim form, a claim shall be deemed to be a claim for the highest Disease Level for which the claim qualifies at the time of filing, and all lower Disease Levels for which the claim may also qualify, whether at the time of filing or in the future, shall be treated as subsumed by and merged into the higher Disease Level for both processing and payment purposes. Medical Evidence A claim must satisfy the applicable medical criteria set out in the TDP and listed below and include supporting medical documentation as required by the TDP. All diagnoses of a Disease Level shall be accompanied by either (i) a statement by the physician providing the diagnosis that at least ten (10) years have elapsed between the date of first exposure to asbestos or asbestos-containing products and the diagnosis, or (ii) a history of the Injured Party s exposure sufficient to establish a 10-year latency period. (TDP 5.6(a)(1)) For a detailed description of the medical evidence requirements by Disease Level see Section 5.6(a) of the TDP. If the Injured Party has been diagnosed with a Scheduled Disease other than the diagnosis upon which the claim is based, the claimant must provide a copy of such diagnosis even if it was made by one of the unacceptable doctors or medical facilities listed below. The Trust will not consider the diagnosis of an unacceptable doctor or medical facility for purposes of evaluating the statute of limitations for the claim so long as the claim is filed with the Trust within three (3) years after the Initial Claims Filing Date. This requirement does not apply to medical or legal evaluations by purely consulting experts that are protected by a privilege under applicable state law that has not been waived. Notwithstanding the exception with respect to diagnoses by examining physicians for claims filed against or another defendant in the tort system prior to July 12, 2010, if the holder of such a claim (i) has available a report of a diagnosing physician engaged by the holder or his or her law firm or 2
3 Instructions For Filing a Claim With (ii) has filed a report of a diagnosing physician not engaged by the holder or his or her law firm with another asbestos-related personal injury settlement trust, the holder shall provide such medical evidence to the Trust. (TDP 5.6(a)(1)(A) and 5.6(a)(1)(C)) Unacceptable Doctors and Medical Facilities The Trust must have reasonable confidence that the medical evidence provided in support of the claim is credible and consistent with recognized medical standards. (TDP 5.6(a)(2)) The Trust has determined, based on currently available information, that medical reports or medical evidence from certain doctors and medical facilities may not meet the reliability standards of this section. Accordingly, until further notice, the Trust will not accept medical reports and/or medical evidence from the following doctors and medical facilities: Dr. James Ballard, Dr. Kevin Cooper (of Pascagoula, Mississippi), Dr. Todd Coulter, Dr. Andrew Harron, Dr. Ray Harron, Dr. Glynn Hilbun, Dr. Barry Levy, Dr. George Martindale, Dr. Gregory Nayden, Dr. W. Allen Oaks, Netherland & Mason, Inc., Respiratory Testing Services, Inc. and Occupational Diagnostics. Medical/Exposure Criteria (TDP 5.2(a)(3)) Level I: Asbestosis/Pleural Disease: (1) Diagnosis of a Bilateral Asbestos-Related Nonmalignant Disease, and (2) six months Leslie Controls Exposure prior to December 31, 1986, and (3) five years cumulative occupational exposure to asbestos. Level II: Asbestosis/Pleural Disease: (1) Diagnosis of Bilateral Asbestos-Related Nonmalignant Disease plus (a) TLC less than 80%, or (b) FVC less than 80% and FEV1/FVC ratio greater than or equal to 65%, and (2) six months Leslie Controls Exposure prior to December 31, 1986, (3) Significant Occupational Exposure to asbestos, and (4) supporting medical documentation establishing asbestos exposure as a contributing factor in causing the pulmonary impairment in question. Level III: Severe Asbestosis: (1) Diagnosis of asbestosis with ILO of 2/1 or greater, or asbestosis determined by pathological evidence of asbestosis, plus (a) TLC less than 65%, or (b) FVC less than 65% and FEV1/FVC ratio greater than 65%, (2) six months Leslie Controls Exposure prior to December 31, 1986, (3) Significant Occupational Exposure to asbestos, and (4) supporting medical documentation establishing asbestos exposure as a contributing factor in causing the pulmonary impairment in question. Level IV: Other Cancer: (1) Diagnosis of a primary colorectal, laryngeal, esophageal, pharyngeal, or stomach cancer, plus evidence of an underlying Bilateral Asbestos-Related Nonmalignant Disease, (2) six months Leslie Controls Exposure prior to December 31, 1986, (3) Significant Occupational Exposure to asbestos, and (4) supporting medical documentation establishing asbestos exposure as a contributing factor in causing the other cancer in question. Level V: Lung Cancer 2: (1) Diagnosis of a primary lung cancer; (2) Leslie Controls Exposure prior to December 31, 1986, and (3) supporting medical documentation establishing asbestos exposure as a substantial contributing factor in causing the lung cancer in question. Lung Cancer 2 (Level V) claims are claims that do not meet the more stringent medical and/or exposure requirements of Lung Cancer 1 (Level VI) claims. All claims in Disease Level V shall be individually evaluated. The estimated likely average of the individual evaluation awards for this category is $18,000 for Leslie Powerhouse and Below-Deck Naval Station Claims and $5,000 for Leslie Construction and Maintenance Claims, with such awards capped at $22,000 for Leslie Powerhouse and Below-Deck Naval Station Claims and $10,000 for Leslie Construction and Maintenance Claims, unless the claim qualifies for Extraordinary Claim treatment (discussed in Section 5.3 of the TDP). Level V claims that show no evidence of either an underlying Bilateral Asbestos-Related Nonmalignant Disease or Significant Occupational Exposure may be individually evaluated, although it is not expected that such claims shall be treated as having any 3
4 Instructions For Filing a Claim With significant value, especially if the claimant is also a Smoker. In any event, no presumption of validity shall be available for claims in this category. Level VI: Lung Cancer 1 : (1) Diagnosis of a primary lung cancer plus evidence of an underlying Bilateral Asbestos Related Nonmalignant Disease, (2) six months Leslie Controls Exposure prior to December 31, 1986, (3) Significant Occupational Exposure to asbestos, and (4) supporting medical documentation establishing asbestos exposure as a contributing factor in causing the lung cancer in question. Level VII: Mesothelioma: (1) Diagnosis of mesothelioma; and (2) Leslie Controls Exposure as defined in Section 5.6(b)(3) of the TDP. Claim Form Part 3: STATUTE OF LIMITATIONS 3.1: Provide the Injured Party s current state of residence or, if deceased, the state of residence at the time of the Injured Party s death. 3.2: Check the box indicating whether a tolling agreement applies. Provide a copy of the tolling agreement, if applicable. Respond to items if an asbestos-related lawsuit was filed against on behalf of the Injured Party. 3.3: Provide the city, county, state and court where the lawsuit was filed. 3.4: Provide the date on which the lawsuit was originally filed. 3.5: Provide the docket or case number of the lawsuit. 3.6: Check the box indicating whether a final non-appealable judgment was entered against Leslie Controls, Inc. in the lawsuit. Claim Form Part 4: LESLIE CONTROLS SPECIFIC OCCUPATIONAL EXPOSURE AND SIGNIFICANT OCCUPATIONAL EXPOSURE There is currently NO approved Jobsite List for Part 4 must be completed if the claimant claims that the Injured Party s asbestos-related disease is a direct result of the Injured Party s occupational asbestos exposure. Exposure Evidence Section 5.6(b)(1) of the TDP states: In General. As set forth above in Section 5.2(a)(3), to qualify for any Disease Level, the claimant must demonstrate a minimum exposure to asbestos-containing products, or to conduct that exposed the claimant to an asbestos-containing product, for which Leslie Controls has legal responsibility. Claims based on conspiracy theories that involve no exposure to an asbestos-containing product sold, distributed, marketed, handled, processed or manufactured by Leslie Controls are not compensable under these Asbestos PI Trust Distribution Procedures. To meet the presumptive exposure requirements of Expedited Review set forth in Section 5.2 (a)(3) above, the claimant must show (i) for all Disease Levels, Leslie Controls Exposure as defined in Section 5.6(b)(3) below prior to 4
5 Attorney Instructions For Filing A Claim With December 31, 1986, (ii) for Asbestos/Pleural Disease Level I, six (6) months Leslie Controls Exposure prior to December 31, 1986 plus five (5) years cumulative occupational asbestos exposure, and (iii) for Asbestosis/Pleural Disease (Disease Level II), Severe Asbestosis (Disease Level III), Other Cancer (Disease Level IV) or Lung Cancer 1 (Disease Level VI), the claimant must show six (6) months of Leslie Controls Exposure prior to December 31, 1986, plus Significant Occupational Exposure to asbestos as defined below. If a claimant asserting a claim in Disease Level III, IV, V, VI or VII cannot meet the relevant presumptive exposure requirements for a Disease Level eligible for Expedited Review, such claimant may seek Individual Review of his or her claim based on exposure to asbestos-containing products, or to conduct that exposed the claimant to an asbestos-containing product, for which Leslie Controls has legal responsibility. 4.1: Leslie Controls Asbestos Exposure Provide the name of the Injured Party s employer, along with the city and state of the employer, the site or location of alleged exposure and the dates employment began and ended. Provide the Injured Party s profession or a description of the job in which he or she was employed while exposed to the asbestos-containing product sold, distributed, marketed, handled, processed or manufactured by, as well as a description of the exposure and the product. Attach work history to establish meaningful and credible Leslie Controls Exposure prior to December 31, 1986, plus Significant Occupational Exposure to asbestos, as applicable. Section 5.6(b) (3) of the TDP States: Leslie Controls Exposure. The claimant must demonstrate meaningful and credible exposure, which occurred prior to December 31, 1986, (a) to an asbestos-containing product sold, distributed, marketed, handled, processed or manufactured by Leslie Controls or for which Leslie Controls otherwise has legal responsibility, or (b) to conduct for which Leslie Controls has legal responsibility that exposed the claimant to an asbestos-containing product ( Leslie Controls Exposure ). That meaningful and credible exposure evidence may be established by an affidavit or sworn statement on personal knowledge of the claimant, by an affidavit or sworn statement on personal knowledge of a co-worker or the affidavit or sworn statement on personal knowledge of a family member in the case of a deceased claimant (provided that the Asbestos PI Trust finds such evidence reasonably reliable), by invoices, employment, construction or similar records, or by other credible evidence. The specific exposure information required by the Asbestos PI Trust to process a claim under either Expedited or Individual Review shall be set forth on the proof of claim form to be used by the Asbestos PI Trust. The Asbestos PI Trust can also require submission of other or additional evidence of exposure when it deems such to be necessary. Evidence submitted to establish proof of Leslie Controls Exposure is for the sole benefit of the Asbestos PI Trust, not third parties or defendants in the tort system. The Asbestos PI Trust has no need for, and therefore claimants are not required to furnish the Asbestos PI Trust with, evidence of exposure to specific asbestos products other than those for which Leslie Controls has legal responsibility, except to the extent such evidence is required elsewhere in these Asbestos PI Trust Distribution Procedures. Similarly, failure to identify Leslie Controls Exposure in the claimant s underlying tort action, or to other bankruptcy trusts, does not preclude the claimant from recovering from the Asbestos PI Trust, provided that the claimant satisfies the medical and exposure requirements of these Asbestos PI Trust Distribution Procedures. 4.2: Significant Occupational Exposure for Claims other than Mesothelioma Claims 5
6 Attorney Instructions For Filing A Claim With Check the appropriate box(es) to indicate the basis of the Injured Party s Significant Occupational Exposure. Section 5.6(b) (2) of the TDP States: Significant Occupational Exposure. Significant Occupational Exposure means 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 claimant (a) handled raw asbestos fibers on a regular basis, (b) fabricated asbestos-containing products so that the claimant in the fabrication process was exposed on a regular basis to raw asbestos fibers, (c) altered, repaired or otherwise worked with an asbestos-containing product such that the claimant was exposed on a regular basis to asbestos fibers, or (d) was employed in an industry and occupation such that the claimant worked on a regular basis in close proximity to workers engaged in the activities described in (a), (b) and/or (c). Claim Form Part 5: SECONDARY EXPOSURE: EXPOSURE THROUGH AN OCCUPATIONALLY EXPOSED PERSON Part 5 must be completed if the claimant claims that the Injured Party s asbestos-related disease is a result of asbestos exposure through an occupationally exposed person ( OEP ). Section 5.4 of the TDP States: Secondary Exposure Claims. If a claimant alleges an asbestos-related disease resulting solely 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 5.2(b) above. In such a case, the claimant must establish that the occupationally exposed person would have met the exposure requirements under these Asbestos PI Trust Distribution Procedures that would have been applicable had that person filed a direct claim against the Asbestos PI Trust. In addition, the claimant with secondary exposure must establish that he or she is suffering from one of the seven Disease Levels described in Section 5.2(a)(3) above or an asbestos-related disease otherwise compensable under these Asbestos PI Trust Distribution Procedures, that his or her own exposure to the occupationally exposed person occurred within the same time frame as the occupationally exposed person was exposed to asbestos-containing products or conduct for which Leslie Controls has legal responsibility, and that such secondary exposure was a cause of the claimed disease. All other liquidation and payment rights and limitations under these Asbestos PI Trust Distribution Procedures shall be applicable to such claims, including the right to elect Scheduled Value. 5.1 Injured Party s Exposure Through OEP Provide the period during which the Injured Party was regularly exposed to asbestos through the OEP identified in 5.2. Describe the Injured Party s relationship with the OEP and the 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 Provide the full name of the OEP. Provide the name of the OEP s employer, along with the city and state of the employer, the site or location of alleged exposure and the dates employment began and ended. 6
7 Attorney Instructions For Filing A Claim With Provide the OEP s profession or a description of the job in which he or she was employed while exposed to the asbestos-containing product(s) sold, distributed, marketed, handled, processed or manufactured by, as well as a description of the exposure and the product. Attach work history for the OEP to establish meaningful and credible Leslie Controls Exposure prior to December 31, 1986, plus Significant Occupational Exposure to asbestos, as applicable. 5.3 OEP s Significant Occupational Exposure for Claims other than Mesothelioma Claims Check the appropriate box(es) to indicate the basis of the OEP s Significant Occupational Exposure. Claim Form Part 6: PROOF OF EXPOSURE The Injured Party or the Official Representative may complete Part 8: CERTIFICATION of the 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 Injured Party s attorney or the Official Representative may complete Part 8: CERTIFICATION of the 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). Part 6 lists additional documentation that must be provided for Leslie Powerhouse and Below-Deck Naval Station Claims and additional documentation that may be provided to supplement credibility as to proof of exposure. Claim Form Part 7: INDIVIDUAL REVIEW INFORMATION Part 7 must be completed only if the claimant is seeking Individual Review of his or her claim. 7.1: Provide information regarding the Injured Party s smoking history. 7.2: Provide information regarding economic loss. 7.3: Provide information regarding the Injured Party s heirs. 7.4: Check the box 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. Claim Form Part 8: CERTIFICATION Sign the Claim Form and check the appropriate box(es) identifying the person who is certifying the Claim Form and the capacity in which the certification is provided. 7
8 Filing Deadlines (TDP 5.1(a)(2)): Attorney Instructions For Filing A Claim With All unliquidated Asbestos PI Claims must meet either: (i) (ii) for claims first filed in the tort system against prior to the Commencement Date (i.e., July 12, 2010), the applicable federal, state or foreign statute of limitations and repose that was in effect at the time of the filing of the claim in the tort system; or for claims not filed against in the tort system prior to the Commencement Date, the applicable federal, state or foreign statute of limitations that was in effect at the time of the filing with the Trust. However, the running of the applicable statute of limitations shall be tolled as of the earliest of: (A) (B) (C) the actual filing of a claim against prior to the Commencement Date in the tort system; the date specified by agreement or otherwise between Leslie Controls, Inc. and/or the Trust, on the one hand, and the applicable claimant, on the other hand, (or, if none, the date of the agreement) in the case of the tolling prior to the Commencement Date by an agreement or otherwise, provided such tolling was still in effect on the Commencement Date; or the Commencement Date. If an Asbestos PI Claim meets any of the tolling provisions described in the preceding paragraph and the claim was not barred by the applicable federal, state or foreign statute of limitations at the time of the relevant tolling event, it shall be treated as timely filed if it is actually filed with the Trust within three (3) years after the Initial Claims Filing Date. In addition, any Asbestos PI Claim that is first diagnosed after the Commencement Date, irrespective of the application of any relevant federal, state or foreign statute of limitations or repose, may be filed with the Trust within three (3) years after the date of diagnosis or within three (3) years after the Initial Claims Filing Date, whichever is later. However, the processing of any Asbestos PI Claim by the Trust may be deferred at the election of the claimant pursuant to Section 6.3 of the TDP. 8
9 Scheduled, Average and Maximum Values: Attorney Instructions For Filing A Claim With The Scheduled, Average and Maximum Values for claims involving Disease Levels I-VII are as follows (TDP 5.2(b)(3)): Leslie Powerhouse and Below-Deck Naval Station Claims: Scheduled Disease Scheduled Value Average Value Maximum Value Mesothelioma (Level VII) $100,000 $140,000 $350,000 Lung Cancer 1 (Level VI) $25,000 $35,000 $125,000 Lung Cancer 2 (Level V) N/A $18,000 $22,000 Other Cancer (Level IV) $15,000 $17,500 $25,500 Severe Asbestosis (Level III) $17,500 $20,000 $30,000 Asbestosis/Pleural Disease (Level II) $4,500 $4,500 $4,500 Asbestosis/Pleural Disease (Level I) $1,500 $1,500 $1,500 Leslie Construction and Maintenance Claims: Scheduled Disease Scheduled Value Average Value Maximum Value Mesothelioma (Level VII) $25,000 $30,000 $125,000 Lung Cancer 1 (Level VI) $7,500 $10,000 $37,500 Lung Cancer 2 (Level V) N/A $5,000 $10,000 Other Cancer (Level IV) $5,000 $7,500 $15,000 Severe Asbestosis (Level III) $6,000 $8,000 $17,500 Asbestosis/Pleural Disease (Level II) $1,250 $1,250 $1,250 Asbestosis/Pleural Disease (Level I) $500 $500 $500 Payments All payments made by the Trust on account of Asbestos PI Claims shall be subject to the applicable Payment Percentage. (TDP 2.3 and IV) Releases: A Release will be generated and sent when an offer is made. The Trust requires return of the original individual (hard copy) Release or an electronic image thereof. 9
10 Attorney Instructions For Filing A Claim With Where to Submit Claim Forms: Claim submissions for should be sent to: -Individual Claims Electronic Filing Option (user ID and Password required) o lesliecontrolsasbestostrust.com (PDF format) Mail to: Asbestos Injury Trust c/o MFR Claims Processing, Inc. 115 Pheasant Run Suite 112 Newtown, PA Bulk Upload Claims Electronic Filing (user ID and Password required) o lesliecontrolsasbestostrust.com Requesting Information: You may contact MFR Claims Processing, Inc. 115 Pheasant Run Suite 112 Newtown, PA Ph: