PEL-Claim Information

Claim information is as follows. The required information is bold. You may choose to upload information for Litigation, Smoking History, or Exposure History or all of them at once. Please see the requirements for each section.

• • AttorneyID

    • this is provided by CRMC

  • ContactID

    • • this is provided by CRMC

  • LawFirm Representing At Liquidation

    • • yes/no answer to question:

• Liquidated FirstName

  • Liquidated MI

• Liquidated LastName

  • Liquidated Suffix

  • Liquidated State Of Residence

    • • (state codes)

  • Earliest Exposure Date

• • • earliest date of exposure to an asbestos-containing product

• AllegedDisease Code

• • • Please select one:

      • • NON

          • • Non-malignancy

        • COL

          • • Colorectal

        • LAR

          • • Laryngeal

        • ESO

          • • Esophageal

        • PHA

          • • Pharyngeal

        • STO

          • • Stomach Cancer

        • LC

          • • Lung Cancer

        • MES

          • • Mesothelioma

• • First Diagnosis Date

• • • date of first diagnosis of an asbestos-related disease

• • Settlement Amount Awarded

• • • Claim amount as fixed or liquidated under the settlement agreement or pursuant to final judgment

• • Settlement Amount Owed

• • • If a portion of the claim has already been satisfied and/or the Trust is not liable for payment of the entire claim amount, specify the unpaid portion of the claim which claimant alleges the Trust is responsible for paying

• • Settlement Award Date

• • • Date claim was established by final judgment, or by settlement agreement

• • Subject To Appeal

    • • yes/no answer to question:

  • Claim Secured

    • • yes/no answer to question: Is claim secured by letter of credit, appeal bond or other security or surety?

  • Secured Nature

    • • if yes for 'Claim Secured'; Nature of the security

  • Secured's FirstName

    • • if yes for 'Claim Secured';

  • Secured's MI

    • • if yes for 'Claim Secured';

  • Secured's LastName

    • • if yes for 'Claim Secured';

  • Secured's Suffix

    • • if yes for 'Claim Secured';

  • Secured Amount

    • • if yes for 'Claim Secured'; Amount of security

  • Secured Address

    • • if yes for 'Claim Secured';

  • Secured Phone

    • • if yes for 'Claim Secured';