DOCUMENT CHECKLIST - FOR SUBMISSION OF CLAIMS ON BEHALF OF PERSONAL INJURY CLAIMANTS
Updated: May 8, 2013
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Documentation Confirming Presence at a 9/11 Crash Site Between September 11, 2001 and May 30, 2002, which can include the following examples of acceptable proof:
- For Responders: Employer records confirming employment with an organization or entity that was responsible for rescue and recovery, clean up, transportation of debris, and confirming that the Claimant was present at the site, including an official personnel roster, site credentials or a pay stub; OR contemporaneous documentation of presence – such as orders, instructions, confirmation of tasks performed, contemporaneous medical records, or contemporaneous records of federal, state, city or local government.
- For Residents: Proof of residence in the area during the relevant time period such as (i) rent receipts, mortgage receipts, or utility bills and (ii) proof that the Claimant was physically present at the residence at some point between September 11, 2001 and May 30, 2002, which could include at least two sworn and notarized affidavits (or unsworn statements complying with 28 U.S.C. 1746) from co-habitants, landlords, doormen, or neighbors.
- For Non-Responder Workers in NYC Exposure Zone or at the Pentagon: Employment records documenting employment and presence in the NYC Exposure Zone or at the Pentagon; OR contemporaneous documentation of presence – such as contemporaneous medical records or contemporaneous records of federal, state, city or local government.
- For School or Child/Adult Care Facility Attendees: School or day care records confirming enrollment/attendance during the period.
- For Presence in NYC Exposure Zone in some other capacity (e.g., a visitor): Contemporaneous documentation of presence – such as contemporaneous medical records or contemporaneous records of federal, state, city or local government.
NOTE: At least two (2) sworn and notarized affidavits (or unsworn statements complying with 28 U.S.C. 1746) regarding the presence of the Claimant from persons who can attest to the Claimant’s presence at a 9/11 crash site will serve as acceptable proof only if other official or “primary” forms of proof (such as those listed above) are not available and the Fund determines that such affidavits are sufficiently reliable. All affidavits should be original (with an original handwritten signature and the original notary stamp/seal) and should be submitted by mail to the VCF.
Documentation About the Claimant’s Physical Injury or Condition
- For any claimed injuries or conditions that have been treated under the WTC Health Program that commenced on July 1, 2011:
- The VCF will advise if further documents are needed. But note that if Claimant was also treated outside of the WTC Health Program, you may need to submit those certified medical records.
- For any claimed injuries or conditions that have been treated by another program or another private doctor:
- The VCF will send medical history forms to your physician(s). The VCF will use those forms to determine whether the Claimant has a diagnosis of a presumptively eligible condition and whether the condition was a direct result of the air crashes or debris removal. If the records obtained from the physician do not provide all the information the VCF needs, the VCF will contact you and request additional records. If the VCF requests more records, you will need to provide certified contemporaneous medical records and documents created by or at the direction of the medical professional(s) who provided the medical care showing the diagnosis of an injury or condition that is presumptively eligible under the VCF. If you have medical records that you have collected (certified or not) you may submit them at any time and this may help the VCF to evaluate your claim.
NOTE: The documentation should include proof of when each injury or condition was discovered and when each injury or condition was first treated by a medical professional.
Documentation Demonstrating Any Applicable Economic Loss
- For any claim of unreimbursed medical or other expenses, proof such as invoices or receipts for prescription drugs, rehabilitation treatment, or from the Claimant’s health provider showing payments received, and documentation of any health insurance coverage during any period of claimed medical expense loss.
- For any claim of future medical expenses, a statement from a treating physician regarding your prognosis and need for ongoing treatment, any documentation that you believe is relevant to a determination of your claim, and documentation of any current health insurance coverage.
- For any claim of loss of earnings to date, documentation to demonstrate how many days of work were missed and the corresponding loss of compensation and/or benefits, such as pay stubs, salary letters, end of year pay statements, or sworn and notarized affidavit (or unsworn statement complying with 28 U.S.C. 1746) from your employer describing the work missed and loss of earnings.
- For any claim of replacement service loss to date, documentation such as invoices or receipts showing services rendered and payments received. If you are claiming loss of future replacement services, documentation of type and costs of replacement services expected to be incurred in the future (e.g., estimates or price quotes for future services) and documentation of any disability determination (see below).
- For any claim of loss of future earnings:
- Documentation of any disability determination by any workers compensation carrier, SSA, any other government agency, insurer, or physician with respect to your disability. (If such a determination has not been made, you will need to submit other documentation regarding your disability and/or capacity to work in the future, such as evaluations or reports from doctors or medical experts.)
- Copies of all tax return information (including W-2 forms and other attachments) for the period beginning three years prior to any claimed decrease in the Claimant’s earnings capacity as a result of the Claimant’s disability or if no such decrease is claimed, three years prior to the year claim is being filed, including returns for non-U.S. taxing authorities.
- Documentation of Claimant’s compensation history for the period beginning three calendar years prior to the decrease in the Claimant’s earnings capacity as a result of the claimant’s disability or if no such decrease is claimed, three years prior to the year the claim is being filed with the VCF. Examples of the types of proof include:
- Documentation to establish base salary and wages, such as pay stubs, salary letters, or end of year pay statements.
- Documentation to establish any other compensation, including incentive pay, bonuses, overtime, tips, commissions, shift differentials, longevity and honoraria, deferred compensation, stock options, profit sharing programs such as pay stubs, salary letters, end of year pay statement, bonus letters, or commission letters.
- Documentation on any pension, health or other benefits:
- Pension plan or pension section from employee handbook if Claimant received pension benefits.
- Documentation to establish payroll deduction and cost of employer-provided health benefits to employee and any other covered person if Claimant received health benefits.
- 401(k)/403(b) statements if employer made matching contributions.
- Documentation to establish any other benefits, such as employer-provided transportation subsidy or company car, employer provided club dues/memberships, or non-military housing allowance.
NOTE: For Claimants who were in the armed forces – Include information on housing, subsistence, TAD, re-enlistment, and other compensation by each category. However, if you want the Special Master to rely on published compensation and benefit scales, there is no need to provide information on this additional compensation, but you will need to submit a copy of the Claimant’s Military Leave and Earnings Statement indicating the pay level and benefit information.
NOTE: The Special Master recognizes that collecting this information may be a difficult task and will seek to work with the Claimant’s employer(s) to obtain and confirm compensation and benefits and make sure they have been calculated correctly.
Documentation of any Collateral Sources of Compensation that the Claimant has received or is entitled to receive, including:
- Social Security application or determination or related correspondence
- Workers’ Compensation application or determination or related correspondence
- Medical payments
- Short-term disability insurance
- Long-term disability insurance
- Other Collateral Source Compensation
Other Documentation That May Be Applicable
- If Claimant was involved in a lawsuit related to September 11, 2001, provide a copy of either:
- For purposes of the Eligibility Form, you may submit either a court order establishing that the action has been discontinued and/or dismissed dated on or before January 2, 2012 or a notice/letter of withdrawal filed on the ECF system in the relevant docket on or before January 2, 2012. For purposes of receiving compensation, you should submit the final order of the court confirming the withdrawal or dismissal or all claims. That order may be dated after January 2, 2012 only if you have provided proof that you filed a notice of withdrawal on the ECF system in the relevant docket on or before January 2, 2012.
- If possible, submit the settlement agreement and release showing the date of the settlement and release, the total settlement amount, and the medical condition that was approved for payment under the settlement if available. If the attorney of the Claimant or Claimant’s dependent, spouse or beneficiary signed and submitted the release, you should also provide a copy of the retainer agreement with the attorney in the settled lawsuit as proof that the attorney was authorized to sign the release.
NOTE: In many cases, the VCF may be able to obtain documents related to September 11th-related lawsuits from third parties. Therefore, you should still submit your claim even if you do not have the documents listed above. The VCF will notify you if you need to submit anything else.
- If you have filed a lawsuit or claim for compensation for the claimed condition(s) with any court or bankruptcy trust for any respiratory injury or disease due to exposure unrelated to September 11, 2001 (e.g., asbestos), you should submit information on the action or claim, such as the complaint or claim filing, and documentation of any judgment, settlement or trust compensation.
- If someone is submitting the claim on behalf of a minor or incapacitated Claimant or a deceased individual:
- Parent(s) of a Minor Claimant: (1) Claimant’s birth certificate; and (2) Court order granting one parent sole custody of Claimant (if applicable).
- Guardian or Other Person with Legal Custody of a Minor Claimant: (1) Court order granting custody or appointing guardianship; or (2) Will or deed appointing guardianship.
- Guardian of a Non-Minor Claimant: Court order appointing guardianship.
- Representative of a Deceased Individual: Any court order appointing personal representative and any will appointing executor or administrator.