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
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';