SHOOK & FLETCHER ASBESTOS SETTLEMENT TRUST
INDIRECT TRUST CLAIM
PROOF OF CLAIM FORM
Submit completed claims to:
Shook & Fletcher Asbestos Settlement Trust
c/o MFR Claims Processing, Inc.
115 Pheasant Run, Suite 112
Newton, PA 18940
Instructions for the Submitting an Indirect Trust Claim[1]
- For purposes of this Claim Form, the term “Indirect Trust Claimant”refers to the entity seeking contribution, reimbursement, subrogation, indemnification or other similar paymentunder any other theory of indirect liability from the Shook & Fletcher Asbestos Settlement Trust (the “Trust”). The “Direct Trust Claimant” is the person whose underlying asbestos personal injury or wrongful death gives rise to the Indirect Trust Claim.
- A separate Claim Form must be filed for each underlying Direct Trust Claimant so that each Indirect Trust Claim may be evaluated individually. Complete the Claim Form as thoroughly and accurately as possible.
- If you have any questions, please review the information posted on the Trust’s website at or contact MFR Claims at .
SECTION A: Indirect Trust Claimant
This section is to be completed by each person or entity asserting an Indirect Trust Claim.
A1. Identification of Person or Entity Asserting Indirect Trust Claim
IndirectTrust Claimant: ______
(First Name, Middle Initial, Last Name or Entity Name)
Current Street Address: ____________
(Street/P.O. Box number/ Suite number)
______
(City, State and Zip)
Telephone: ______
(Area Code & Number)
Soc. Sec. No. or Fed. Empl. I. D. No.: ______
Nature of Business: ______
Name of Contact Person: _______
(First Name, Middle Initial, Last Name)
Title: ______
Current Street Address: ______
(Street/P.O. Box number/ Suite number)
______
(City, State and Zip)
Telephone: ______Fax: ______
(Area Code & Number)(Area Code & Number)
E-mail Address:______
A2. Identification of Attorney for Indirect Trust Claimant
Attorney Name: ______
(First Name, Middle Initial, Last Name)
Name of Law Firm: ______
(Please provide full name)
Current Street Address: ______
(Street/P.O. Box number/ Suite number)
______
(City, State and Zip)
Telephone: ______Fax: ______
(Area Code & Number)(Area Code & Number)
Email Address: ______
A3. Amount of This Indirect Trust Claim
Total amount claimed: $______
Total amount of award, judgment, or settlement: $______
A4. Identification of Direct Trust Claimant (Injured Party)
Name:______
(First Name, Middle Initial, Last Name)
Social Security No.: ______-______-______
Date of Birth: ______/______/______
(Month) (Day) (Year)
Disease/injury for which the Indirect Trust Claimant compensated the Direct Trust Claimant: ______
SECTION B: Legal Basis for Indirect Trust Claim
This section is to be completed by each person or entity asserting an Indirect Trust Claim pursuant to the Trust’s Claims Resolution Procedures (the “CRP”).
B1. Indirect Trust Claim
Section 5.5 of the CRP states, among other things, that an Indirect Trust Claim may not be processed or paid by the Trustee unless (a) such claim has not been disallowed under Section 502(c) of the Bankruptcy Code, and (b) the Indirect Trust Claimant establishes to the satisfaction of the Trustee that (i) the Indirect
Trust Claimant has paid in full the liability and obligations of the Trust to the Direct Trust Claimant, (ii) the Direct Trust Claimant and the Indirect Trust Claimant have forever and fully released the Trust from all liability to the Direct Trust Claimant, and (iii) the claim is not otherwise barred by a statute of limitations or repose or by other applicable law.
B2. Theory of Recovery
Describe below fully the legal and factual basis of your claim, including whether your claimis one for contribution, reimbursement, subrogation or indemnification, or is based upon another theory of indirect liability under applicable law or other basis for reimbursement.
Identify in your answer the state or other jurisdiction whose laws you contend are applicable to and support your claim, and the basis for the application of that state’s or other jurisdiction’s laws.
Explain in the space below how this Indirect Trust Claim satisfies each of the criteria set out in Section 5.5 of the CRP (including the criteria noted in section B1 above). Provide the specific statutory and case authority which you contend support this claim.
If the space provided on this form is insufficient, please provide this information on additional sheets of paper to be attached behind this sheet.
Additional information and supporting documentation may be required by the Trust.
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______
______
______
______
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Is your Indirect Trust Claim based on having paid all or part of the alleged equitable share of liability of Shook & Fletcher Insulation Co., Inc. (“Shook & Fletcher”) or the Trust, for an asbestos-related personal injury or wrongful death claim? Yes___No ____
Please List: $______Total Liability Paid by Indirect Trust Claimant
$______Trust’s Liability Paid by Indirect Trust Claimant
$______Indirect Trust Claimant’s Share of Total Liability
Describe below the basis on which you have computed Shook & Fletcher’s or the Trust’s share, your share, and the shares to be paid by any other person or entity (including all co-defendants).
______
______
______
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Are you aware of any payment by Shook & Fletcher or the Trust in respect of this claim?
Yes___No ____
If yes, please explain:
______
______
______
______
______
B3. Proof of Payment
Provide copies of canceled checks, receipted bills, vouchers or other information showing that you paidthe Direct Trust Claimant, or a party who paid the Direct Trust Claimant, in the amount claimed. Such proof of payment to the Direct Trust Claimant is required in all circumstances.
SECTION C: Proof of Claim and Related Claims Information
C1. Proof of Claim
A. Did you file a Proof of Claim in the Shook & Fletcher’s bankruptcy case? Yes___No ____
If yes, please attach the Bankruptcy Proof of Claim to this Claim Form.
C2. Related Claims
Have you sought, are you seeking, or do you plan to seek contribution, reimbursement, subrogation, indemnification, or payment on any other basis from any other asbestos producer, entity, individual or trust (other than the Trust) based upon the same Direct Trust Claim? Yes___No ____
If yes, please provide the following information for each person or entity from whom or which you have sought, are seeking or plan to seek any recovery. If these claims involve lawsuits or other dispute resolution proceedings, please attach a copy of the complaint (or other document setting out the claim) and any judgment (or other determination of the merits of the claim).
Attach additional sheets for each defendant where seeking compensation related to the Direct Trust Claimant.
Name of Entity: ______
Amount of Claim: $______
Type of Proceeding (lawsuit, negotiation, prior agreement, etc.): ______
Basis of Claim: ______
Status or outcome of the claim: ______
______
______
______
If the claim is in the nature of a lawsuit or other dispute resolution proceeding, please provide the following:
Court or Other Dispute Resolution Forum, including Case Number and Other Identifying Information:
______
SECTION D: Statutes of Limitation and Repose
This section is to be completed by each person or entity asserting an Indirect Trust Claim pursuant to the Trust’s Claims Resolution Procedures (the “CRP”).
D1. Requirements of the CRP
Section 5.2(b) of the CRP states:
To be eligible for a placein the FIFO Processing Queue, a CRP Valued Asbestos Claim must be filed with the Trust within three (3) years after the date of the diagnoses, or within four (4) years after the Effective Date, whichever occurs later, irrespective of the application of any relevant federal, state or foreign statute of limitation or repose; provided, however, that nothing in this Section 5.2(b) shall be construed as tolling any applicable statute of limitation or repose in respect of any claim that had run prior to the Petition Date. However, the running of the relevant statute of limitation shall be tolled as of the earliest of (A) the actual filing of the claim against Shook & Fletcher prior to the Petition Date, whether in the tort system or by submission of the claim to Shook & Fletcher or CCR pursuant to a written settlement agreement; (B) the filing of the claim against another defendant in the tort system prior to the Petition Date if the claim was tolled against Shook & Fletcher or CCR at the time by an agreement or otherwise; (C) the filing of a claim after the Petition Date but prior to the Effective Date against another defendant in the tort system; (D) the filing of a proof of claim in the Chapter 11 Case prior to the Effective Date; or(E) the filing of a proof of claim with the requisite supporting documentation with the Trust afterthe Effective Date.
If a Trust Claim meets any of the tolling provisions described in subsection (A), (B), (C),(D) or (E) of the preceding sentence, it will be treated as timely filed provided that theappropriate claim form is actually filed with the Trust within four (4) years of the Effective Date. Also, any claims that were first diagnosed after the Petition Date, irrespective of the applicationof any relevant statute of limitation or repose, may be filed with the Trust within three (3) years after the date of diagnosis, or within four (4) years after the Effective Date, whichever occurs later.
D2. Timeliness of this Claim
Date of Diagnosis of the Direct Trust Claimant: ______
Is this Indirect Trust Claim being filed with the Trust within three (3) years after the date of diagnosis of the Direct Trust Claimant? Yes ______No ______
If you answered “No” to the prior question, explain why you believe this Indirect Trust Claim is nonetheless timely under the terms of section 5.2(b) of the CRP:
______
SECTION E: Signature of Indirect Trust Claimant
E1. Signature of Indirect Trust Claimant or Representative
THE UNDERSIGNED DECLARES UNDER PENALTY OF PERJURY, PURSUANT TO 28 U.S.C. §1746 AND 18 U.S.C. §152, THAT (i) HE OR SHE IS AUTHORIZED TO FILED THIS CLAIM ON BEHALF OF THE INDIRECT TRUST CLAIMANT IDENTIFIED ABOVE, AND (ii) THE INFORMATION SUBMITTED IN THIS PROOF OF CLAIM IS TRUE AND CORRECT.
______
First Name, Middle Initial, Last Name
(If signed by a Representative of the Indirect Trust Claimant,Signature
must be signed by a Corporate Officer or Attorney in Charge)
______
Title
______
Date
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[1] To the extent this Claim Form conflicts with the Trust’s Claims Resolution Procedures, those Procedures control.