Common use of Eligibility Form Clause in Contracts

Eligibility Form. The Special Mas- ter shall develop an Eligibility Form, which may be a portion of a complete claim form, that will require the claimant to provide information nec- xxxxxx for determining the claimant’s eligibility to recover from the Fund. (1) The Eligibility Form may require that the claimant certify that he or she has dismissed any pending lawsuit seeking damages as a result of the ter- rorist-related airplane crashes of Sep- tember 11, 2001, or for damages arising from or related to debris removal (ex- cept for actions seeking collateral source benefits) no later than January 2, 2011 and that there is no pending law- suit brought by a dependent, spouse, or beneficiary of the victim. (2) The Special Master may require as part of the notice requirement pur- suant to § 104.4(b) that the Personal Representative of the deceased indi- vidual provide copies of a designated portion of the Eligibility Form to the immediate family of the decedent (in- cluding, but not limited to, the spouse, former spouses, children, other depend- ents, and parents), to the executor, ad- ministrator, and beneficiaries of the decedent’s will, and to any other per- sons who may reasonably be expected to assert an interest in an award or to have a cause of action to recover dam- ages relating to the wrongful death of the decedent. (3) The Eligibility Form may require claimants to provide the following proof: (i) Proof of death: Death certificate or similar official documentation; (ii) Proof of presence at site: Docu- mentation sufficient to establish pres- ence at a 9/11 crash site, which may in- clude, without limitation, a death cer- tificate, proof of residence, such as a lease or utility bill, records of employ- ment or school attendance, contem- poraneous medical records, contem- poraneous records of federal, state, city or local government, a pay stub, offi- cial personnel roster, site credentials, an affidavit or declaration of the dece- dent’s or injured claimant’s employer, or other sworn statement (or unsworn statement complying with 28 U.S.C. 1746) regarding the presence of the xxx- xxx; (iii) Proof of physical harm: Certifi- cation of a conclusion by the WTC Health Program that the claimant suf- fers from a WTC-Related Physical Health Condition and is eligible for treatment under the WTC Health Pro- gram, or verification by the WTC Pro- gram Administrator that the claimant suffers from a WTC-Related Physical Health Condition, or other credible medical records from a licensed med- ical professional.

Eligibility Form. The Special Mas- ter shall develop an Eligibility Form, which may be a portion of a complete claim form, that will require the claimant to provide information nec- xxxxxx for determining the claimant’s eligibility to recover from the Fund. (1) The Eligibility Form may require that the claimant certify that he or she has dismissed any pending lawsuit seeking damages as a result of the ter- rorist-related airplane crashes of Sep- tember 11, 2001, or for damages arising from or related to debris removal (ex- cept for actions seeking collateral source benefits) no later than January 2, 2011 and that there is no pending law- suit brought by a dependent, spouse, or beneficiary of the victim. (2) The Special Master may require as part of the notice requirement pur- suant to § 104.4(b) that the Personal Representative of the deceased indi- vidual provide copies of a designated portion of the Eligibility Form to the immediate family of the decedent (in- cluding, but not limited to, the spouse, former spouses, children, other depend- ents, and parents), to the executor, ad- ministrator, and beneficiaries of the decedent’s will, and to any other per- sons who may reasonably be expected to assert an interest in an award or to have a cause of action to recover dam- ages relating to the wrongful death of the decedent. (3) The Eligibility Form may require claimants to provide the following proof: (i) Proof of death: Death certificate or similar official documentation; (ii) Proof of presence at site: Docu- mentation sufficient to establish pres- ence at a 9/11 crash site, which may in- clude, without limitation, a death cer- tificate, proof of residence, such as a lease or utility billxxxx, records of employ- ment or school attendance, contem- poraneous medical records, contem- poraneous records of federal, state, city or local government, a pay stub, offi- cial personnel roster, site credentials, an affidavit or declaration of the dece- dent’s or injured claimant’s employer, or other sworn statement (or unsworn statement complying with 28 U.S.C. 1746) regarding the presence of the xxx- xxx; (iii) Proof of physical harm: Certifi- cation of a conclusion by the WTC Health Program that the claimant suf- fers from a WTC-Related Physical Health Condition and is eligible for treatment under the WTC Health Pro- gram, or verification by the WTC Pro- gram Administrator that the claimant suffers from a WTC-Related Physical Health Condition, or other credible medical records from a licensed med- ical professional.