Page 1 of 9 This Claim Form sets forth your claim for recovery under

WTC DEBRIS REMOVAL LITIGATION
TIER 1 CLAIM FORM
INSTRUCTIONS:
This Claim Form sets forth your claim for recovery under the Final Settlement Agreement. Where
indicated in this Claim Form, additional records must be provided together with this Claim Form to
support your claims, as required by the Final Settlement Agreement.
If you have any questions regarding this Claim Form, raise those issues with your attorney.
If any portion of this Claim Form was prepared for you, review its contents carefully.
You are responsible for any material misrepresentations, material omissions or material concealment
in this Claim Form.
After filling in pages 1-5 of this Claim Form electronically, it must be printed and signed before a
Notary Public by all Plaintiffs, Personal Representatives, if any, and Counsel.
This Claim Form and all supporting records must be submitted to the Allocation Neutral within
ninety (90) days of the Final Settlement Agreement Effective Date.
FRAUD WARNING:
Any person who knowingly presents false information or conceals material
information called for on this Claim Form is guilty of a crime, including but not
limited to perjury, and may be subject to criminal prosecution, confinement in prison,
and monetary fines and penalties. In addition, any such person shall be denied any
and all benefits of the settlement and shall be subject to court action seeking the return
of any monies paid to that person as part of the settlement prior to discovery of the
knowingly false or concealed information, as well as all costs, attorneys’ fees and
expenses incurred by the parties to the settlement as a result of the knowingly false or
concealed information.
PART 1: PRIMARY PLAINTIFF PERSONAL INFORMATION
A. Current Legal Name:
Plaintiff
Primary
Family Name (Last), and Suffix if applicable
Given Name (First)
M.I.
Given Name (First)
M.I.
B. Any Prior Legal Name(s):
Family Name (Last), and Suffix if applicable
C. Identification Number:
U.S. Social Security Number:
Or Alternate Identification
D. Date of Birth:
000-00-0000
Type:
Jan. 1, 1901
No.:
E. Primary Plaintiff is: Alive; skip Parts 5 and 6
F. Home Address:
Street Number and Street Name
Apt. No.
00000
City
G. Marital Status:
I. Counsel:
Single
State
H. Date of Marriage to Derivative Plaintiff:
Plaintiff's Attorney
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Zip Code
[insert if applicable]
WTC DEBRIS REMOVAL LITIGATION
TIER 1 CLAIM FORM
FOR PRIMARY PLAINTIFF
PART 2: PRIMARY PLAINTIFF AFFIRMATIONS
A. Required Affirmations from all Primary Plaintiffs (must check all boxes):
Primary Plaintiff is included on the Eligible Plaintiff List with Primary Injury code:
.
Primary Plaintiff worked or volunteered at the WTC Site or at another location at which
9/11-related clean-up work or other services occurred and which form the basis for the Primary
Plaintiff’s claims.
Primary Plaintiff did not recover from the September 11th Victim Compensation Fund.
Primary Plaintiff has no outstanding liens against him or her relating to any payments
received under the Final Settlement Agreement or will satisfy fully any and all liens against him
or her.
B. Required Affirmations for all Primary Plaintiffs with Derivative Plaintiffs:
Primary Plaintiff lawfully married the Derivative Plaintiff before Sept. 11, 2001.
Primary Plaintiff remained lawfully married to and cohabitated with the Derivative Plaintiff
as of the Primary Plaintiff’s last day of work or volunteer service at the WTC Site and/or at
another location at which the Primary Plaintiff alleges exposure giving rise to his or her claims.
PART 3: DERIVATIVE PLAINTIFF PERSONAL INFORMATION (Skip if No Derivative Plaintiff)
A. Current Legal Name:
Plaintiff
Derivative
Family Name (Last), and Suffix if applicable
Given Name (First)
M.I.
Given Name (First)
M.I.
B. Any Prior Legal Name(s):
Family Name (Last), and Suffix if applicable
C. Identification Number:
U.S. Social Security Number:
Or Alternate Identification
000-00-0000
Type:
No.:
D. Home Address:
Street Number and Street Name
Apt. No.
00000
City
State
Zip Code
PART 4: DERIVATIVE PLAINTIFF AFFIRMATIONS (Skip if No Derivative Plaintiff)
Required Affirmations from all Derivative Plaintiffs (must check all boxes):
Derivative Plaintiff is included on the Eligible Plaintiff List.
Derivative Plaintiff lawfully married the Primary Plaintiff before Sept. 11, 2001.
Derivative Plaintiff remained lawfully married to and cohabitated with the Primary Plaintiff
as of the Primary Plaintiff’s last day of work or volunteer efforts at the WTC Site and/or at
another location at which the Primary Plaintiff alleges exposure giving rise to his or her claims.
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WTC DEBRIS REMOVAL LITIGATION
TIER 1 CLAIM FORM
FOR PRIMARY PLAINTIFF
PART 5: PERSONAL REPRESENTATIVE OF DECEASED PLAINTIFF (Skip if Primary Plaintiff is alive)
A. Current Legal Name:
Representative
Personal
Family Name (Last), and Suffix if applicable
Given Name (First)
M.I.
B. Home Address:
Street Number and Street Name
Apt. No.
00000
City
State
Zip Code
Attach probate order, court order or other official document establishing Personal Representation.
PART 6: BENEFICIARY OF DECEASED PLAINTIFF (Skip if Primary Plaintiff is alive)
A. Current Legal Name:
BeneficiaryLN
BeneficiaryFN
Family Name (Last), and Suffix if applicable
Given Name (First)
M.I.
B. Home Address:
Street Number and Street Name
Apt. No.
00000
City
State
Zip Code
Attach probate order, court order or other official document identifying beneficiary.
PART 7: COMPLAINT CHARACTERIZATION INFORMATION
Type of Complaint:
Plaintiff(s) has/have a complaint pending in the Southern District of New York (S.D.N.Y.)
with civil action number: 00 CV 00000, in Master Docket Not Applicable.
Plaintiff(s) has/have a complaint pending outside the S.D.N.Y. in [insert name of court]
with civil action number: [insert civil action number].
PART 8: PRELIMINARY CRITERIA FOR ELIGIBILITY TO RECOVER
A. Work Verification (check relevant box):
Primary Plaintiff is on the work verification pre-approval list
Primary Plaintiff is not on the work verification pre-approval list, but is providing with this
Claim Form documentation that the Primary Plaintiff contends is sufficient for the Allocation
Neutral to conclude that Primary Plaintiff worked or volunteered at the WTC Site or at another
location at which 9/11-related clean-up work or other services occurred and which form the
basis for the Primary Plaintiff’s claims, consistent with the Work Verification Procedure
attached as Exhibit B to the Final Settlement Agreement.
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WTC DEBRIS REMOVAL LITIGATION
TIER 1 CLAIM FORM
FOR PRIMARY PLAINTIFF
PART 8: PRELIMINARY CRITERIA FOR ELIGIBILITY TO RECOVER
B. Release and Covenant Not to Sue and Second Injury Letter (check all that apply):
Primary Plaintiff has signed the Release and Covenant Not to Sue.
Derivative Plaintiff has signed the Release and Covenant Not to Sue.
Primary Plaintiff signed the Second Injury Letter in the presence of a Notary Public.
C. Cancer Insurance Policy Eligibility (check relevant box):
Primary Plaintiff has been provided with a Cancer Insurance Policy application form,
believes he or she is eligible, and will apply for coverage.
Primary Plaintiff has been provided with a Cancer Insurance Policy application form and
understands that he or she must apply if eligible, but does not intend to apply for coverage
because the Primary Plaintiff already has or had a cancer covered by the Cancer Insurance
Policy.
PART 9: MARINE EXPOSURE CLAIMS
Allegations of Marine Exposure:
Primary Plaintiff does not allege exposure on a vessel, such as a barge, owned by the City
of New York or Weeks Marine, Inc., or at a pier, dock, or other location used by such vessels
(skip to Part 10).
Primary Plaintiff alleges exposure on a vessel, such as a barge, owned by the City of New
York or Weeks Marine, Inc., or at a pier, dock, or other location used by such vessels
(“Alleged Marine Exposure”) (complete the rest of this Part):
Primary Plaintiff’s employer during his or her Alleged Marine Exposure was: [insert
employer name].
Primary Plaintiff’s work relating to his or her Alleged Marine Exposure consisted of:
[insert description of work at marine locations, including role and responsibilities].
Alleged Marine Exposure constituted 00% of Primary Plaintiff’s total alleged exposure
supporting his or her Debris Removal Claims.
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WTC DEBRIS REMOVAL LITIGATION
TIER 1 CLAIM FORM
FOR PRIMARY PLAINTIFF
PART 10: LIEN DISCLOSURES
A. Government Benefits:
Primary Plaintiff has not received any government healthcare benefits since his or her first
date of alleged exposure (skip to part 10.B); OR
Primary Plaintiff has received government healthcare benefits since his or her first date of
alleged exposure, specifically (check all that apply):
Medicare – HICN or Medicare ID No. [insert number]
Medicaid
Department of Veterans Affairs (VA)
TRICARE
Other government healthcare program: [insert name of program]
B. Benefits from Non-Governmental Healthcare Providers or Insurers:
Primary Plaintiff has had a non-governmental healthcare provider or insurer pay for care
related to his or her Debris Removal Claim and related injuries (check all that apply):
Private Health Insurance Policy No. [insert number], through [insert name of
Insurance Company(-ies)]
Employer Health Plan through [insert name of Employer(s)]
Workers’ Compensation benefit(s) through [insert name of Employer(s)]
Medicare Advantage Plan through [insert name of Private Insurer]
MediGap/Medicare Supplemental Insurance through [insert name of Private Insurer]
Other [explain compensation program and identify source]
Primary Plaintiff has NOT received any of the above-mentioned benefits at any time since
his or her first date of alleged exposure.
C. Benefits Correspondence:
Primary Plaintiff has received correspondence or inquiries regarding his or her claim from
one of the above-mentioned healthcare benefit providers and has provided those materials to
his or her counsel.
Primary Plaintiff has not received correspondence or inquiries regarding his or her claim
from one of the above-mentioned healthcare benefit providers.
Primary Plaintiff has not received correspondence or inquiries regarding any claim from
one of the above-mentioned healthcare benefit providers.
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WTC DEBRIS REMOVAL LITIGATION
TIER 1 CLAIM FORM
FOR PRIMARY PLAINTIFF
PRIMARY PLAINTIFF’S SIGNATURE PAGE
FRAUD WARNING:
Any person who knowingly presents false information or conceals material
information called for on this Claim Form is guilty of a crime, including but not
limited to perjury, and may be subject to criminal prosecution, confinement in prison,
and monetary fines and penalties. In addition, any such person shall be denied any
and all benefits of the settlement and shall be subject to court action seeking the return
of any monies paid to that person as part of the settlement prior to discovery of the
knowingly false or concealed information, as well as all costs, attorneys’ fees and
expenses incurred by the parties to the settlement as a result of the knowingly false or
concealed information.
PRIMARY PLAINTIFF ATTESTATION
Pursuant to 28 U.S.C. § 1746, I declare under penalty of perjury under the laws of the United
States of America that the foregoing is true and correct, and that all documents submitted with this
Claim Form are true and correct copies of original records.
Executed on: __________ ___, 20__.
__________________________
PRIMARY PLAINTIFF
On ___________ ___, 20__, before me, _________________________, Notary Public,
personally appeared Primary Plaintiff, personally known to me (or proved to me on the basis of
satisfactory evidence) to be the person whose name is subscribed to the written instrument and
acknowledged to me that he executed the same in his authorized capacity, and that by his signature
on the instrument the person, or the entity upon behalf of which the person acted, executed the
instrument.
WITNESS my hand and official seal
______________________________
Notary Public in and for the
______________________________
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WTC DEBRIS REMOVAL LITIGATION
TIER 1 CLAIM FORM
FOR PRIMARY PLAINTIFF
DERIVATIVE PLAINTIFF’S SIGNATURE PAGE (IF NECESSARY)
FRAUD WARNING:
Any person who knowingly presents false information or conceals material
information called for on this Claim Form is guilty of a crime, including but not
limited to perjury, and may be subject to criminal prosecution, confinement in prison,
and monetary fines and penalties. In addition, any such person shall be denied any
and all benefits of the settlement and shall be subject to court action seeking the return
of any monies paid to that person as part of the settlement prior to discovery of the
knowingly false or concealed information, as well as all costs, attorneys’ fees and
expenses incurred by the parties to the settlement as a result of the knowingly false or
concealed information.
DERIVATIVE PLAINTIFF ATTESTATION
Pursuant to 28 U.S.C. § 1746, I declare under penalty of perjury under the laws of the United
States of America that the foregoing is true and correct, and that all documents submitted with this
Claim Form are true and correct copies of original records.
Executed on: __________ ___, 20___.
__________________________
DERIVATIVE PLAINTIFF
On ___________ ___, 20__, before me, _________________________, Notary Public,
personally appeared Derivative Plaintiff, personally known to me (or proved to me on the basis of
satisfactory evidence) to be the person whose name is subscribed to the written instrument and
acknowledged to me that he executed the same in his authorized capacity, and that by his signature
on the instrument the person, or the entity upon behalf of which the person acted, executed the
instrument.
WITNESS my hand and official seal
______________________________
Notary Public in and for the
______________________________
Page 7 of 9
WTC DEBRIS REMOVAL LITIGATION
TIER 1 CLAIM FORM
FOR PRIMARY PLAINTIFF
PLAINTIFFS’ COUNSEL’S SIGNATURE PAGE
FRAUD WARNING:
Any person who knowingly presents false information or conceals material
information called for on this Claim Form is guilty of a crime, including but not
limited to perjury, and may be subject to criminal prosecution, confinement in prison,
and monetary fines and penalties. In addition, any such person shall be denied any
and all benefits of the settlement and shall be subject to court action seeking the return
of any monies paid to that person as part of the settlement prior to discovery of the
knowingly false or concealed information, as well as all costs, attorneys’ fees and
expenses incurred by the parties to the settlement as a result of the knowingly false or
concealed information.
PLAINTIFF’S COUNSEL ATTESTATION
Pursuant to 28 U.S.C. § 1746, I declare under penalty of perjury under the laws of the United
States of America that the foregoing is true and correct to the best of my knowledge, information and
belief, and that all documents submitted with this Claim Form are true and correct copies of original
records to the best of my knowledge, information and belief.
Executed on: __________ ___, 20___.
__________________________
PLAINTIFF'S ATTORNEY
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WTC DEBRIS REMOVAL LITIGATION
TIER 1 CLAIM FORM
FOR PRIMARY PLAINTIFF
PERSONAL REPRESENTATIVE’S SIGNATURE PAGE (IF NECESSARY)
FRAUD WARNING:
Any person who knowingly presents false information or conceals material
information called for on this Claim Form is guilty of a crime, including but not
limited to perjury, and may be subject to criminal prosecution, confinement in prison,
and monetary fines and penalties. In addition, any such person shall be denied any
and all benefits of the settlement and shall be subject to court action seeking the return
of any monies paid to that person as part of the settlement prior to discovery of the
knowingly false or concealed information, as well as all costs, attorneys’ fees and
expenses incurred by the parties to the settlement as a result of the knowingly false or
concealed information.
PERSONAL REPRESENTATIVE ATTESTATION
Pursuant to 28 U.S.C. § 1746, I declare under penalty of perjury under the laws of the United
States of America that the foregoing is true and correct, and that all documents submitted with this
Claim Form are true and correct copies of original records.
Executed on: __________ ___, 20__.
__________________________
Personal Representative
On ___________ ___, 20__, before me, _________________________, Notary Public,
personally appeared Personal Representative, personally known to me (or proved to me on the basis
of satisfactory evidence) to be the person whose name is subscribed to the written instrument and
acknowledged to me that he executed the same in his authorized capacity, and that by his signature
on the instrument the person, or the entity upon behalf of which the person acted, executed the
instrument.
WITNESS my hand and official seal
______________________________
Notary Public in and for the
______________________________
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