Williams Emtal Talc Settlement Fund

CAP Regarding Unavailable Estates

Standard Claim Form

This Claim Form is for use for all Claim submissions submitted by the Injured Person or his/her Personal Representative. If the Injured Person is deceased and no estate is open, please use the Alternate Claim Form below.

Standard Claim Form Verification

For Online Filers: All Claims submitted online require a signed verification. This form must be signed by hand and not electronically. Please use this Verification Form for all Standard Claim Form submissions. It will also be available in the Portal when completing your claim. If you are mailing in a paper Claim Form, your signature must be provided in Section 11 and this form is not necessary.

Alternate Claim Form

If the Injured Person in an Underlying Lawsuit is deceased and no estate is open, this Claim Submission Form may be submitted by the spouse or child, acting with written unanimous consent of all other living children. Alternate Claims are only eligible for Part A compensation. If the Injured Person in an Underlying Lawsuit is deceased and no estate is open, this Claim Submission Form may be submitted by the spouse or child, acting with written unanimous consent of all other living children. Alternate Claims are only eligible for Part A compensation.

Alternate Claim Form Verification

For Online Filers: All Claims submitted online require a signed verification. This form must be signed by hand and not electronically. Please use this Verification Form for all Alternate Claim Form submissions. It will also be available in the Portal when completing your claim. If you are mailing in a paper Claim Form, your signature must be provided in Section 9 and this form is not necessary.

Supporting Documentation Requirements

The type of documentation needed to support your claim depends on the compensation type that has been selected (A, B, C) and whether the claimant is on the Presumed Class Member list. This document provides a summary of the documentation needed for all claims.

Ineligible Diagnostician List

Medical records provided by these physicians will not be accepted to support medical criteria for Part B claims.

CAP Regarding Unavailable Estates

Claimant Attorney?s/Claimant?s Declaration re: Claimant?s Identification

A Claimant must establish to the Settlement Fund?s satisfaction its identity and relationship to an Underlying Lawsuit by meaningful and credible evidence that (a) the Claimant (and Claimant?s decedent if applicable) is the person or is the personal representative or heir of the person named in the Underlying Lawsuit the claim is based upon; or (b) is the person, personal representative or heir of a person listed on the Presumed Class Member List. You may use this form to verify the identity of the Claimant. This form may be used by the Claimant to establish his/her identity and relationship to an Underlying Lawsuit.

Claimant Attorney?s Declaration re: Claimant?s Identification and Underlying Action?s Asssertion of Good faith, Credible Asbestos Injury Claim

All Claimants who are not Presumed Class Members must provide documentary proof satisfactorily establishing that the Underlying Lawsuit was asserting a good faith, credible injury claim based on an injury believed to be caused by exposure Emtal Talc. This affidavit may be used to provide details to support the basis of the Underlying Lawsuit and support this requirement. This affidavit may also be used to satisfy the Identity Validation requirement for all claims.

Part A Certification of No Supporting Documents

To be eligible for payment, all claims must supply a copy of a pleading, interrogatory answer, or deposition testimony describing the Injured Person?s alleged exposure unless no such supporting documentation is available. Please use this form if you are unable to obtain any documents to meet this requirement after diligent search and inquiry.

QAT Polling Assistance Request Form

If you are applying for the Supplemental Injury Severity (SIS) Based Compensation Program (Part B), you will need to provide support for the injury that is claimed in your submission. If you want for the Administrator to search for claims filed with Qualified Asbestos Trusts to support this injury, please submit this form with your claim. Along with this form, please provide at least one medical record.

Part B Certification of No Supporting Documents

All claims where QAT Polling has been requested must supply a medical record or a medical report that documents the Injured Person?s asbestos injury as part of the Claim Submission, unless no such supporting documentation is available. Please use this form if you are unable to obtain any records after diligent search and inquiry.

Extraordinary Injury Fund (EIF) Application Form

The Plan?s Part C compensation program provides a discretionary Extraordinary Injury Fund (?EIF?) from which the Settlement Trustee may award a discretionary EIF award to Claimants who prove extraordinary and exceptional circumstances and who meet the POD criteria. Please use this form if you are applying for Part C compensation.

Extraordinary Injury Fund (EIF) Eligibility Waiver Form

If you are applying for Part C compensation and are unable to provide all of the required documentation, please use this form to request a waiver.

Settlement Trustee Adjudication Request

This form may be used to inform the Settlement Fund that the Claimant is requesting review and determination of any contested issue(s) before the Settlement Trustee and to specify the reasons for the appeal or challenge.

Lien Questionnaire ? Authorization to Disclose Health Information

This Lien Questionnaire must be completed for all claimants, but does not need to be included in the initial Claim submission.

Medicare Proof of Representation Form

This Form must be completed for all claimants, but does not need to be included in the initial Claim submission.

Lien Questionnaire Asbestos with Medicare Part C and D

This Lien Questionnaire must be completed for all claimants, but does not need to be included in the initial Claim submission.

Texas Medicaid Medical Authorization

This document is only needed for claimants who are Texas residents. If filing online, this form will also be available in the Williams Emtal Talc Lucid Portal.

Florida HIPAA Compliant Medical Release

This form is only needed for Florida residents. If filing online, this form will also be available in the Williams Emtal Talc Lucid Portal.