Personal Injury Compensation Form and Death Compensation Form. The Spe- cial Master shall develop a Personal In- jury Compensation Form, which may be a portion of a complete claim form, that each injured claimant must sub- mit. The Special Master shall also de- velop a Death Compensation Form, which may be a portion of a complete claim form, that each Personal Rep- resentative must submit. These forms shall require the claimant to provide certain information that the Special Master deems necessary to determining the amount of any award, including in- formation concerning income, collat- eral sources, benefits, settlements and attorneys’ fees relating to civil actions described in section 405(c)(3)(C)(iii) of the Act, and other financial informa- tion, and shall require the claimant to state the factual basis for the amount of compensation sought. It shall also allow the claimant to submit certain other information that may be rel- evant, but not necessary, to the deter- mination of the amount of any award. (1) The Special Master may ask claimants to submit certain tax re- turns or tax transcripts for returns that the Special Master deems appro- priate for determination of an award. The Special Master may also require waivers, consents, or authorizations from claimants to obtain directly from third parties medical information, em- ployment information, or other infor- mation that the Special Master deems relevant to determining the amount of any award. (2) Claimants may attach to the ‘Per- xxxxx Injury Compensation Form’’ or ‘‘Death Compensation Form’’ any addi- tional statements, documents or anal- yses by physicians, experts, advisors, or any other person or entity that the claimant believes may be relevant to a determination of compensation.
Appears in 4 contracts
Samples: Confidentiality Agreement, Confidentiality Agreement, Confidentiality Agreement
