CLAIM FORM
Baycol Settlement
TO BE ELIGIBLE FOR COMPENSATION YOUR COMPLETE CLAIM FORM TOGETHER WITH
SUPPORTING DOCUMENTATION MUST BE FAXED TO THE CLAIMS ADMINISTRATOR OR MAILED TO
THE CLAIMS ADMINISTRATOR AND POSTMARKED NO LATER THAN NOVEMBER 26, 2006
You must complete all pages of this Form. Attach additional pages if space is insufficient.
Please type or print legibly in black ink.
IDENTIFICATION OF CLAIMANT
Name of Class 1 Member:
Address:
Street
City
Province
Postal Code
Telephone :
Area code / Phone no. (Ext. if applicable)
Name of Executor, etc.
of person taking Baycol:
(if applicable)
Address:
Street
City
Province
Postal Code
Telephone:
Area code/Phone no. (Ext. if applicable)
PLEASE INFORM THE CLAIMS ADMINISTRATOR OF ALL ADDRESS CHANGES IN WRITING
1.
IDENTIFICATION OF THE BASIS OF THE CLASS 1 MEMBER’S CLAIM:
Level I: Rhabdomyolysis contemporaneously with ingestion of Baycol. No hospitalization required..
Level II: Rhabdomyolysis contemporaneously with ingestion of Baycol. Hospitalization was required but not
dialysis was necessary.
Level III: Rhabdomyolysis contemporaneously with ingestion of Baycol. Hospitalization was required and dialysis
or other exceptional hospital treatment was necessary.
Level IV: Rhabdomyolysis contemporaneously with ingestion of Baycol. Hospitalization was required. Person
continues to require permanent dialysis on an ongoing basis or died of a cause directly attributed to rhabdomyolysis.
Level V: Rhabdomyolysis contemporaneously with ingestion of Baycol which caused other serious injury not
contemplated in Levels I-IV or claims where cause of rhabdomyolysis is disputed.
2.
THE FOLLOWING SUPPORTING DOCUMENTATION MUST BE SUBMITTED WITH THIS CLAIM FORM
AND IS ATTACHED:
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All medical and hospital records relat