Document 64
Filed 10/14/2005
Page 1 of 48
IN THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF DELAWARE
: : USG CORPORATION, : a Delaware corporation, et al., : : Debtors. : ___________________________________ : USG CORPORATION, et al., : : Movant : : v. : : OFFICIAL COMMITTEE OF ASBESTOS PERSONAL : INJURY CLAIMANTS, OFFICIAL COMMITTEE OF : UNSECURED CREDITORS, OFFICIAL : COMMITTEE OF ASBESTOS PROPERTY : DAMAGE CLAIMANTS AND LEGAL : REPRESENTATIVE FOR FUTURE CLAIMANTS, : : Respondents. :
In re:
Chapter 11 Jointly Administered Case No. 01-2094 (JKF)
Civil Action No. 04-1559 (JFC) Civil Action No. 04-1560 (JFC)
DEBTORS' STANDARD QUESTIONNAIRE TO SELECT PERSONAL INJURY ASBESTOS CLAIMANTS
COOLEY GODWARD LLP Stephen C. Neal (CA 170085) Scott D. Devereaux (CA 146050) 3000 El Camino Real Five Palo Alto Square Palo Alto, CA 94306 Tel: (650) 843-5000 RICHARDS, LAYTON, & FINGER, P.A. Daniel J. DeFranceschi (DE No. 2732) Paul N. Heath (DE No. 3704) P.O. Box 551 One Rodney Square Wilmington, Delaware 19899 Tel: (302) 651-7700 JONES DAY David G. Heiman (OH 0038271) Brad B. Erens (IL 6206864) North Point 901 Lakeside Avenue Cleveland, Ohio 44114-1190 Tel: (216) 586-3939
Counsel for Debtors
Answer separately and truthfully in writing each of the questions in this Questionnaire in accordance with the Questionnaire's Definitions and Instructions. Read the entire Questionnaire carefully before completing it. Your completed Questionnaire and all attachments must be post-marked for return mailing to Rust Consulting, Inc. on or before January 9, 2006. Make sure that you and your attorney, if you have one, sign the last page of the Questionnaire under oath. Completion of this Questionnaire is mandatory under Federal Rules of Civil Procedure, Rules 26 and 33, made applicable to this proceeding by Federal Rules of Bankruptcy Procedure 7026 and 7033.
Case 1:04-cv-01560-JFC
Document 64 DEFINITIONS
Filed 10/14/2005
Page 2 of 48
The words in CAPITALS in the Questionnaire are defined as follows: 1. The INJURED PARTY is the person who allegedly has or had a medical condition caused by asbestos exposure, including but not limited to MESOTHELIOMA, LUNG CANCER, OTHER CANCER, PLEURAL PLAQUES, DIFFUSE PLEURAL THICKENING, ASBESTOSIS, or other non-malignant asbestos-related condition. The PERSONAL REPRESENTATIVE OF THE INJURED PARTY is the person or entity that is filing the claim on behalf of the INJURED PARTY if the INJURED PARTY is legally incompetent or deceased. This person or entity may be, for example, the INJURED PARTY's legal guardian, executor, or administrator. This person or entity is not the attorney representing the INJURED PARTY or the attorney representing the PERSONAL REPRESENTATIVE OF THE INJURED PARTY. The CLAIMANT is either the INJURED PARTY or, if the INJURED PARTY is legally incompetent or deceased, the PERSONAL REPRESENTATIVE OF THE INJURED PARTY. DEBTORS are any or all of the following corporations: USG Corporation, United States Gypsum Company, USG Interiors, Inc., USG Interiors International, Inc., L&W Supply Corporation, Beadex Manufacturing, LLC, B-R Pipeline Company, La Mirada Products Co., Inc., USG Industries, Inc., USG Pipeline Company, and Stocking Specialists, Inc. US GYPSUM is United States Gypsum Company. For a description of the businesses of US GYPSUM and other DEBTORS and a listing of the types of products they manufactured or sold that may have contained asbestos, see Appendix B to this Questionnaire. PLEURAL PLAQUES is a non-malignant, circumscribed or localized area of fibrous material appearing in the lining of the lung or the chest wall. DIFFUSE PLEURAL THICKENING is a diffuse (as opposed to circumscribed or localized) area of fibrosis appearing in the lining of the lung or the chest wall. ASBESTOSIS is diffuse fibrosis (or scarring) on both lungs caused by the inhalation of asbestos fibers. LUNG CANCER is a malignant tumor of the lungs.
2.
3. 4.
5.
6. 7. 8. 9.
10. MESOTHELIOMA is a malignant tumor of the pleura, which is the thin membrane or lining surrounding the lung (pleural mesothelioma). It may also be a malignant tumor of the lining of the abdominal cavity (peritoneal mesothelioma). 11. OTHER CANCER is any cancer other than LUNG CANCER or MESOTHELIOMA and includes but is not limited to colon cancer, laryngeal (voicebox) cancer, esophageal cancer, pharyngeal (throat) cancer, stomach cancer, breast cancer, ovarian cancer, liver cancer, brain cancer, lymphoma (cancer of the lymph nodes (or tissues)), and prostate cancer. 12. FORCED VITAL CAPACITY (FVC) describes the total amount of air that can be forcibly and quickly exhaled after inhaling as much air as possible. 13. FORCED EXPIRATORY VOLUME (FEV1) describes the volume of air that can be forced from the lungs in one second of effort. 14. TOTAL LUNG CAPACITY (TLC) represents the total amount of air that can be taken into the lungs, including the air that cannot be exhaled. 15. DIFFUSION CAPACITY (DLCO or DCO) measures the exchange of oxygen from the air to the blood stream.
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Document 64 INSTRUCTIONS
Filed 10/14/2005
Page 3 of 48
1.
Read carefully the entire Questionnaire and the Definitions and Instructions before completing the Questionnaire. It is important to read the entire Questionnaire at least once before completing it because you may need to copy some sections prior to filling them out so that you can submit multiple copies of the sections. See Instruction No. 4, below. Type or print your answers to each question neatly and legibly using black or blue ink. Use capital letters and avoid contact with the edge of the character boxes. Mark check boxes with an "X" (example at right). Do not use a felt-tip pen, do not write outside the boxes or blocks, and do not bend or fold the pages of the Questionnaire. Do not distribute this Questionnaire to others for their completion because each Questionnaire has a unique identifying barcode and number for each INJURED PARTY. Be complete, accurate, and truthful in your answers to the questions asked. This Questionnaire is an official court document that may be used as evidence in any legal proceeding regarding your claim. The penalty for knowingly and fraudulently making a false statement under penalty of perjury is a fine of up to $500,000 or imprisonment for up to five years, or both. If you cannot fit all information in any particular section or page, make a copy of that page before filling it out and add the necessary information to the copied page(s). Attach as many additional pages as needed. If the INJURED PARTY is deceased, submit a copy of the death certificate with the Questionnaire. If this Questionnaire is being filed by the PERSONAL REPRESENTATIVE OF THE INJURED PARTY, submit with the Questionnaire written evidence of your authority to act on behalf of the INJURED PARTY. Submit with the Questionnaire copies of the following medical documents: A. B. If in Part 2 you state that the INJURED PARTY has been diagnosed with MESOTHELIOMA, submit a copy of a narrative statement from a diagnosing physician that shows the alleged diagnosis. If in Part 2 you state that the INJURED PARTY has been diagnosed with LUNG CANCER or OTHER CANCER, or with PLEURAL PLAQUES, D IFFUSE PLEURAL THICKENING, ASBESTOSIS, or any other non-malignant asbestos-related condition, submit: i. An original of the INJURED PARTY's most recent radiographic evaluation, such as an x-ray or CT scan, taken before the filing of the INJURED PARTY's claim; ii. Copies of any and all medical reports and records that were relied upon for, or that conflict with, the alleged diagnosis, including but not limited to: · Physical exam results; · Pathology reports; · Diagnostic tests or reports; · Laboratory tests; · Letters or other written statements from a doctor or medical clinic; · Pulmonary function test (PFT) reports, including: · Spirogram tracings; · FORCED VITAL CAPACITY (FVC); · FORCED EXPIRATORY VOLUME (FEV1); · TOTAL LUNG CAPACITY (TLC); · DIFFUSION CAPACITY (DLCO or Dco); and iii. Copies of any and all written statements by a doctor or medical clinic regarding the cause or potential cause of the alleged diagnosis.
2.
3.
4. 5.
6.
If in Part 2 you allege multiple diagnoses, submit copies of all medical documents required for each and every diagnosis that you allege. DEBTORS will reimburse your reasonable expenses incurred in copying the medical documents that you submit. See Instruction No. 10, below. 7. If the INJURED PARTY or the PERSONAL REPRESENTATIVE OF THE INJURED PARTY responded to interrogatories or was deposed in a lawsuit filed by or on behalf of the INJURED PARTY for asbestos-related personal injury, submit with the Questionnaire copies of any and all such interrogatory responses and depositions. If a written claim, including but not limited to a proof of claim form, was submitted by or on behalf of the INJURED PARTY for asbestos-related personal injury in another bankruptcy case or against a trust established pursuant to a plan of reorganization or liquidation in another bankruptcy case, submit with the Questionnaire copies of any and all such written claims. See Part 8 of the Questionnaire. If the INJURED PARTY was exposed to asbestos through another party (the "Source Individual"), and if the Source Individual responded to interrogatories or was deposed in a lawsuit filed by or on behalf of the Source Individual for asbestos-related personal injury, submit with the Questionnaire copies of any and all such interrogatory responses and depositions. If a written claim, including but not limited to a proof of claim form, was submitted on behalf of the Source Individual for asbestos-related personal injury in another bankruptcy case or against a trust established pursuant to a plan of reorganization or liquidation in another bankruptcy case, submit with the Questionnaire copies of any and all such written claims. See Part 9 of the Questionnaire.
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Document 64
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DEBTORS will reimburse your reasonable expenses incurred in copying the interrogatory responses, depositions, and written claims that you submit. See Instruction No. 10, below. 8. If in Part 4 you identify a co-worker or other person upon whom you rely for your belief that the INJURED PARTY was exposed to an asbestos-containing product of US GYPSUM or another DEBTOR, and if that co-worker or other person was deposed in any asbestos-related personal injury action, submit with the Questionnaire copies of any and all such depositions. See Part 4 of the Questionnaire. DEBTORS will reimburse your reasonable expenses incurred in copying the depositions that you submit. See Instruction No. 10, below. In Parts 4-7 of the Questionnaire, you are asked to provide Standard Occupational Classification Codes and Standard Industrial Classification Codes. For a list of these codes, refer to Appendices C and D, respectively, to the Questionnaire.
9.
10. Instead of originals, you may submit copies of any and all documents that the Questionnaire requires with the exception of radiographic evaluations, such as x-rays or CT scans. You must submit the originals of these evaluations. DEBTORS will reimburse your reasonable expenses incurred in copying documents that you submit. In Part 10, indicate the documents for which you seek reimbursement and the total amount of the reimbursement you seek. Attach to this Questionnaire a receipt that shows the copy costs you incurred. Upon request, DEBTORS may have access to the original of any document that you submit. Original documents and radiographic evaluations provided to DEBTORS will be returned within a reasonable time after their professionals and experts have reviewed the documents or evaluations. 11. Make sure that the INJURED PARTY or the PERSONAL REPRESENTATIVE OF THE INJURED PARTY completes and signs the Authorization for Release of Earnings Information and Employment Records From the Social Security Administration contained in Appendix A. You do not need to complete the Request for Social Security Earnings Information Form (Form SSA-7050-F4) that is included in Appendix A with the Authorization. This form is only for your reference. You need only complete and return the Authorization on the first page of Appendix A. A confidentiality agreement entered in this case provides that the following information may be disclosed only to persons involved in the case, that it will be held in strict confidence by persons who receive it, and that it will be used only for purposes related to the case: (1) social security numbers collected in the Questionnaire or its supporting documentation; (2) all records regarding the INJURED PARTY that DEBTORS receive from the Social Security Administration pursuant to the Authorization in Appendix A ("SSA Documents"); (3) information contained in the SSA Documents when disclosed in conjunction with the INJURED PARTY'S name, address, or social security number; and (4) medical records or medical information collected with or in the Questionnaire when disclosed in conjunction with the INJURED PARTY'S name, address, or social security number. 12. If you have questions concerning this Questionnaire or want to request additional copies of it, your attorney may call the toll-free automated helpline of Rust Consulting, Inc. The helpline may be reached at 1-800-611-9738. Rust Consulting cannot provide legal advice. 13. If you prefer to input your responses to the Questionnaire on a computer, you must call Rust Consulting's toll-free automated helpline at 1-800-611-9738 to obtain a copy of the Questionnaire as a writable Portable Document Format (PDF) document. Once you have entered all responses into the PDF document, you must print the document and have the CLAIMANT and the CLAIMANT's attorney, if any, sign the certification in Part 10 of the Questionnaire. Return to Rust Consulting the printed and signed Questionnaire along with all supporting documentation as directed in Instruction No. 14, below. Alternatively, you may convert the printed and signed Questionnaire to a PDF document and return it to Rust Consulting on a CD-ROM as long as: (1) the conversion does not alter the structure or visual presentation of the Questionnaire in any way, including the unique identifying barcode and number at the bottom of each page of the Questionnaire; and (2) the CD-ROM is labeled with the INJURED PARTY'S name, date of birth, and a fully intact, machine-readable copy of the INJURED PARTY'S unique identifying barcode and number. You may also submit any and all of the required supporting documentation as PDF documents on a CD-ROM as long as the CD-ROM complies with this label requirement. Do not submit radiographic evaluations, such as x-rays or CT Scans, on a CD-ROM. However, do label such evaluations with the INJURED PARTY'S name, date of birth, and a fully intact, machine-readable copy of the INJURED PARTY'S unique identifying barcode and number. 14. Make sure that the CLAIMANT and the attorney of the CLAIMANT, if any, signs the Questionnaire in Part 10. Submit your completed Questionnaire and all supporting documentation to the following address: If by mail: If by hand or overnight delivery: Rust Consulting, Inc. Rust Consulting, Inc. P.O. Box 1797 201 S. Lyndale Ave. Faribault, MN 55021-1797 Faribault, MN 55021 Your completed Questionnaire and all supporting documentation must be post-marked for return mailing to Rust Consulting, Inc. on or before January 9, 2006. Do not send your Questionnaire to DEBTORS or DEBTORS' counsel.
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PART 1: IDENTIFYING INFORMATION
Provide identifying information regarding the INJURED PARTY, the PERSONAL REPRESENTATIVE CLAIMANT'S attorney, if any.
OF THE INJURED
PARTY, and the
A. INJURED PARTY the person who allegedly has or had a medical condition caused by asbestos exposure. 1. Full Name:
Last
First
MI
2.
Other Names Used: (including maiden name)
Last
First
MI
3.
Social Security Number:
-
-
*
*
4. 5.
A confidentiality agreement limits disclosure and use of this social security number to persons involved in this case for purposes related to the case. Male Female
Gender: Date of Birth:
/
Month Day
/
Year
6.
The Injured Party is:
Living
Deceased
(If deceased, enclose the death certificate.)
a.
If deceased, date of death:
Month
/
Day
/
Year
b. 7.
If deceased, was death asbestos-related?
Yes
No
If the INJURED PARTY is living, provide that person's mailing address:
Street/P.O. Box
City
State
Zip
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PART 1: IDENTIFYING INFORMATION (Continued)
B. PERSONAL REPRESENTATIVE OF THE INJURED PARTY (not filing attorney) If the I NJURED PARTY is legally incompetent or deceased, and has a PERSONAL REPRESENTATIVE other than, or in addition to, his/her attorney, provide the following information for the PERSONAL REPRESENTATIVE submitting the claim. (Enclose written evidence of your authority to act on behalf of the INJURED PARTY.) 1. Name of PERSONAL REPRESENTATIVE:
Last
First
MI
2.
Relationship to INJURED PARTY: The PERSONAL REPRESENTATIVE is the INJURED PARTY's:
(Guardian, Administrator, Brother, etc.)
3.
PERSONAL REPRESENTATIVE'S mailing address:
Street/P.O. Box
City
State
Zip
C. Attorney If the CLAIMANT is represented by an attorney, provide the following information. 1. Attorney Name:
Last
First
MI
2.
Email Contact Information:
3.
Name of Law Firm:
(Print full name)
4.
Firm Address:
Street/P.O. Box
City
State
Zip
5.
Phone Number: Fax Number:
( (
) )
-
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PART 2: ASBESTOS-RELATED AND OTHER INJURIES
Provide information about the INJURED PARTY's asbestos-related personal injury. 1. Has the INJURED PARTY been diagnosed with cancer? Yes No
2.
If "Yes," identify the type of cancer that was diagnosed for the INJURED PARTY and the date of diagnosis. Refer to the definitions of LUNG CANCER, MESOTHELIOMA, and OTHER CANCER on page 1 of this Questionnaire. LUNG CANCER Date of Diagnosis: Month MESOTHELIOMA Date of Diagnosis: Month OTHER CANCER If OTHER CANCER, identify what type. Date of Diagnosis: Month
/
Year
/
Year
/
Year
3.
a. b.
Has the doctor who made the diagnosis of cancer stated that the cancer in question was caused by asbestos exposure? Has any doctor stated that the cancer in question was caused by asbestos exposure or that asbestos exposure was a substantial contributing factor in the cause of the disease?
Yes
No
Yes Yes
No No
4. 5.
HAS the INJURED PARTY been diagnosed with a non-malignant asbestos-related condition?
If "Yes," identify the type of non-malignant asbestos-related condition that was diagnosed for the INJURED PARTY and the date of diagnosis. Refer to the definitions of PLEURAL PLAQUES, DIFFUSE PLEURAL THICKENING, and ASBESTOSIS on page 1 of this Questionnaire. PLEURAL PLAQUES Date of Diagnosis: Month DIFFUSE PLEURAL THICKENING Date of Diagnosis: Month ASBESTOSIS Other Non-Malignant Asbestos-Related Condition Date of Diagnosis: Month If Other Non-Malignant Asbestos-Related Condition, identify what type. Date of Diagnosis: Month
/
Year
/
Year
/
Year
/
Year
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PART 2: ASBESTOS-RELATED AND OTHER INJURIES (Continued)
6.
a.
Has the doctor who made the diagnosis of non-malignant asbestosrelated condition stated that the condition in question was caused by asbestos exposure? Has any doctor stated that the non-maglignant asbestos-related condition in question was caused by asbestos exposure or that asbestos exposure was a substantial contributing factor in the cause of the condition? Has the INJURED PARTY taken a pulmonary function test (PFT)?
Yes
No
b.
Yes Yes
No No Do Not Know
7.
a. b.
If "Yes," provide all of the following information regarding the INJURED PARTY's most recent pulmonary function test (PFT) results. FORCED VITAL CAPACITY (FVC): Test Date: Month Test Date: Month Test Date: Month Test Date: Month
/
Day
/
Year
Result:
. . . .
Yes
L L L L
% of Predicted:
% % % %
FORCED EXPIRATORY VOLUME (FEV1):
/
Day
/
Year
Result:
% of Predicted:
TOTAL LUNG CAPACITY (TLC):
/
Day
CO
/
Year
Result:
% of Predicted:
DIFFUSION CAPACITY (DLCO or D ):
/
Day
/
Year
Result:
% of Predicted: No Do Not Know
8.
a. b.
Has the INJURED PARTY had an ILO reading of a chest x-ray?
If "Yes," provide information regarding the INJURED PARTY's most recent ILO x-ray reading. Reading Date: Month
/
Day
/
Year
Results:
/
9.
a.
Has the INJURED PARTY been diagnosed with any other lung condition? Yes No Another lung condition includes but is not limited to: (i) chronic obstructive pulmonary disease (including emphysema and chronic bronchitis), (ii) asthma, (iii) pneumonia, (iv) interstitial lung disease (idiopathic pulmonary fibrosis), (v) silicosis, (vi) effusion (fluid around the lung (pleural cavity)), and (vii) congestive heart failure (fluid in the lung) (lung edema). If "Yes," identify the other lung condition.
b.
10. If in Part 2, Question 2, you allege that the INJURED PARTY has been diagnosed with MESOTHELIOMA, complete this question. Otherwise, continue to Question 11. Attach to this Questionnaire a copy of a narrative statement from a diagnosing physician that shows the alleged MESOTHELIOMA diagnosis, and provide the following information regarding the diagnosing physician. a. Doctor's Name:
Last First MI
b.
Doctor's Address:
Street/P.O. Box
City Page 7
State
Zip
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PART 2: ASBESTOS-RELATED AND OTHER INJURIES (Continued) 11. If in Part 2, Question 2, you allege that the INJURED PARTY has been diagnosed with LUNG CANCER or OTHER CANCER, complete this question. Otherwise, continue to Question 12. Attach to this Questionnaire copies of all medical documents identified in Instruction 6, subsection B. See page 2 of the Questionnaire. Provide the following information regarding the INJURED PARTY'S doctor(s). If you allege that the INJURED PARTY has been diagnosed with both LUNG CANCER and OTHER CANCER, or with more than one type of OTHER CANCER, copy this section and complete it for each alleged diagnosis. A. For the doctor who made the alleged diagnosis of LUNG CANCER or OTHER CANCER: a. Doctor's Name:
Last First MI
b.
Doctor's Address:
Street/P.O. Box City State Zip
c.
Doctor's Diagnosis:
LUNG CANCER
OTHER CANCER, Identify what type:
B. For the doctor, if any, who issued the most recent pathology report regarding the alleged diagnosis: a. Doctor's Name:
Last First MI
b.
Doctor's Address:
Street/P.O. Box City State Zip
12. If in Part 2, Question 2, you allege that the INJURED PARTY has been diagnosed with PLEURAL PLAQUES, DIFFUSE PLEURAL THICKENING, ASBESTOSIS, or another non-malignant asbestos-related condition, complete this question. Otherwise, continue to Part 3. Attach to this Questionnaire copies of all medical documents identified in Instruction 6, subsection B. See page 2 of the Questionnaire. Provide the following information regarding the INJURED PARTY'S doctor(s). If you allege that the INJURED PARTY has been diagnosed with more than one non-malignant asbestos-related condition, copy this section and complete it for each alleged diagnosis. A. For the doctor who made the alleged diagnosis of PLEURAL PLAQUES, DIFFUSE PLEURAL THICKENING, ASBESTOSIS , or another non-malignant asbestos-related condition: a. Doctor's Name:
Last First MI
b.
Doctor's Address:
Street/P.O. Box City State Zip
c.
Doctor's Diagnosis: PLEURAL PLAQUES DIFFUSE PLEURAL THICKENING ASBESTOSIS
Other Non-Malignant Asbestos-Related Condition, Specify:
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PART 2: ASBESTOS-RELATED AND OTHER INJURIES (Continued)
B. For the doctor, if any, who issued the most recent pathology report regarding the alleged diagnosis: a. Doctor's Name:
Last First MI
b.
Doctor's Address:
Street/P.O. Box City State Zip
C. For the doctor, if any, who issued the most recent ILO x-ray reading of the INJURED PARTY: a. Doctor's Name:
Last First MI
b.
Doctor's Address:
Street/P.O. Box City State Zip
D. For the doctor, if any, who took the most recent pulmonary function test (PFT) of the INJURED PARTY: a. Doctor's Name:
Last First MI
b.
Doctor's Address:
Street/P.O. Box City State Zip
E.
For the doctor, if any, who most recently treated the INJURED PARTY for the alleged diagnosis: a. Doctor's Name:
Last First MI
b.
Doctor's Address:
Street/P.O. Box City State Zip
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PART 3: SMOKING HISTORY OF THE INJURED PARTY
If in Part 2, you allege that the INJURED PARTY has been diagnosed with MESOTHELIOMA, continue to Part 4. Otherwise, complete this Part. 1. Has the INJURED PARTY ever smoked cigarettes, cigars, or pipes? Yes No
Mark the box(es) that apply and provide the information requested. Age When First Started Smoking Cigarettes: Age Started Cigars: Age Started Pipes: Age Started Month Month / Year Month / Year Pipes per Day: (#) Yes No Date, If Any, When Completely Stopped Smoking / Year Cigars per Day: (#) Average Daily Usage
Packs per Day: (#)
. . .
* * *
2.
Has the INJURED PARTY ever used chewing tobacco or snuff?
Mark the box(es) that apply and provide the information requested. Age When First Started Using Chewing Tobacco: Age Started Snuff: Age Started * Month Month Date, If Any, When Completely Stopped Using Average Daily Usage Number of
/
Year
Times per Day: (#) Number of Times per Day: Year (#)
. .
* *
/
Indicate fractional amounts as appropriate, e.g., three and one-half would be entered as 3.5.
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PART 4: OCCUPATIONAL EXPOSURE TO PRODUCTS OF UNITED STATES GYPSUM COMPANY OR ANY OTHER DEBTOR
Provide information about the INJURED PARTY's occupational exposure to asbestos-containing products that were manufactured or sold by US GYPSUM or any other DEBTOR. In Appendix B to the Questionnaire, you will find a description of the businesses of US GYPSUM and other DEBTORS and a listing of the types of products they manufactured or sold that may have contained asbestos. 1. Did the INJURED PARTY have occupational exposure to an asbestoscontaining product manufactured or sold by US GYPSUM or another DEBTOR? If "Yes," complete the remainder of this Part as instructed. If "No," continue to Part 5. 2. Did the INJURED PARTY have occupational exposure to more than one asbestos-containing product manufactured or sold by US GYPSUM or another DEBTOR? If "Yes," copy this Part and complete the Part for each product. 3. Product Exposed To: (one product per page) Brand Name: Yes No Yes No
Manufacturer of Product: What is the basis for your belief that the exposure was to a DEBTOR'S product and not to another manufacturer's? Personal Recollection Other, Specify:
If you rely on a co-worker of the INJURED PARTY or on another person for your belief that the INJURED PARTY was exposed to a DEBTOR'S product, provide that person's name:
Last
First
MI
If you rely on a co-worker or other person, has this person been deposed in any asbestos-related personal injury action?
Yes
No
If the co-worker or other person has been deposed, attach to this Questionnaire a copy of any and all such depositions. 4. Was the INJURED PARTY exposed to the product in more than one occupation? (Use the Standard Occupational Classification Codes listed in Appendix C.) If "Yes," copy this Part and complete the Part for each occupation. 5. Occupation during exposure: (Use the Standard Occupational Classification Codes listed in Appendix C.) Industry during exposure: (Use the Standard Industrial Classification Codes listed in Appendix D.) Yes No
Specify if "Other":
6.
Specify if "Other":
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PART 4: OCCUPATIONAL EXPOSURE TO PRODUCTS OF UNITED STATES GYPSUM COMPANY OR ANY OF THE DEBTORS (Continued) 7. Provide the date range and frequency of product exposure in the occupation and industry listed in Questions 5 and 6. If exposure was not continuous in the listed occupation and industry, provide all separate date ranges and frequencies of exposure. Start with the first date range of exposure and finish with the last date range of exposure. If there are more than four date ranges of exposure, copy this section before completing it and attach additional pages. For each date range of exposure, describe the exposure type as A, B, C, or D as follows: The INJURED PARTY was: (A) a worker who personally worked with the product identified in Question 3 of this Part; (B) a worker in a room where other workers were personally working with the product identified in Question 3 of this Part; (C) a worker on a floor where other workers were personally working with the product identified in Question 3 of this Part; or (D) a worker at a site where other workers were personally working with the product identified in Question 3 of this Part. Choose the category that best describes the INJURED PARTY'S type of exposure and choose only one category. The best category is the INJURED PARTY'S most typical or most usual form of exposure during the date range at issue. Estimate the frequency of exposure as the average number of man-days per month and hours per man-day that the INJURED PARTY was exposed during the listed date range. If you are unable to do so, then estimate the aggregate number of man-days of exposure during the date range. One man-day of exposure equals eight hours of exposure. Date Range of Exposure: From:
Month
Exposure Type:
Indicate A, B, C or D per Instructions above.
Frequency of Exposure During this Date Range:
Estimate either: Regular Exposure: OR Aggregate Exposure:
/
Year
To:
Month
/
Year
Man-Day(s) per Month
and
Hour(s) per Man-Day
Total Man-Day(s) per Instructions above
Date Range of Exposure: From:
Month
Exposure Type:
Indicate A, B, C or D per Instructions above.
Frequency of Exposure During this Date Range:
Estimate either: Regular Exposure: OR Aggregate Exposure:
/
Year
To:
Month
/
Year
Man-Day(s) per Month
and
Hour(s) per Man-Day
Total Man-Day(s) per Instructions above
Date Range of Exposure: From:
Month
Exposure Type:
Indicate A, B, C or D per Instructions above.
Frequency of Exposure During this Date Range:
Estimate either: Regular Exposure: OR Aggregate Exposure:
/
Year
To:
Month
/
Year
Man-Day(s) per Month
and
Hour(s) per Man-Day
Total Man-Day(s) per Instructions above
Date Range of Exposure: From:
Month
Exposure Type:
Indicate A, B, C or D per Instructions above.
Frequency of Exposure During this Date Range:
Estimate either: Regular Exposure: OR Aggregate Exposure:
/
Year
To:
Month
/
Year
Man-Day(s) per Month
and
Hour(s) per Man-Day
Total Man-Day(s) per Instructions above
8.
Describe the INJURED PARTY'S job duties: (attach additional pages if needed)
9.
Describe how the product identified in Question 3 of this Part was used at the site(s): (attach additional pages if needed)
10. If the exposure(s) listed in response to the above questions was/were at a construction site, estimate the percentage of time such exposure(s) occurred at residential and commercial sites: Residential:
Page 12
%
Commercial:
%
= 100 %
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PART 5: OCCUPATIONAL EXPOSURE TO OTHER ASBESTOS-CONTAINING PRODUCTS
Provide information about the INJURED PARTY's occupational exposure to asbestos-containing products that were not manufactured or sold by US GYPSUM or another DEBTOR. 1. Did the INJURED PARTY have occupational exposure to an asbestoscontaining product that was not manufactured or sold by US GYPSUM or another DEBTOR? If "Yes," complete the remainder of this Part as instructed. If "No," continue to Part 6. 2. Did the INJURED PARTY have occupational exposure to more than one asbestos-containing product that was not manufactured or sold by US GYPSUM or another DEBTOR? If "Yes," copy this Part and complete the Part for each product. 3. Product Exposed To: (one product per page) Brand Name: Yes No Yes No
Manufacturer of Product: 4. Was the INJURED PARTY exposed to the product in more than one occupation? (Use the Standard Occupational Classification Codes listed in Appendix C.) If "Yes," copy this Part and complete the Part for each occupation. 5. Occupation during exposure: (Use the Standard Occupational Classification Codes listed in Appendix C.)
Yes
No
Specify if "Other":
If the INJURED PARTY was exposed to the Product in more than one occupation, copy this Part and complete the Part for each occupation. 6. Industry during exposure: (Use the Standard Industrial Classification Codes listed in Appendix D.)
Specify if "Other":
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PART 5: OCCUPATIONAL EXPOSURE TO OTHER ASBESTOS-CONTAINING PRODUCTS (Continued)
7.
Provide the date range and frequency of product exposure in the occupation and industry listed in Questions 5 and 6. If exposure was not continuous in the listed occupation and industry, provide all separate date ranges and frequencies of exposure. Start with the first date range of exposure and finish with the last date range of exposure. If there are more than four date ranges of exposure, copy this section before completing it and attach additional pages. For each date range of exposure, describe the exposure type as A, B, C, or D as follows: The INJURED PARTY was: (A) a worker who personally worked with the product identified in Question 3 of this Part; (B) a worker in a room where other workers were personally working with the product identified in Question 3 of this Part; (C) a worker on a floor where other workers were personally working with the product identified in Question 3 of this Part; or (D) a worker at a site where other workers were personally working with the product identified in Question 3 of this Part. Choose the category that best describes the INJURED PARTY'S type of exposure and choose only one category. The best category is the INJURED PARTY'S most typical or most usual form of exposure during the date range at issue. Estimate the frequency of exposure as the average number of man-days per month and hours per man-day that the INJURED PARTY was exposed during the listed date range. If you are unable to do so, then estimate the aggregate number of man-days of exposure during the date range. One man-day of exposure equals eight hours of exposure. Date Range of Exposure: From:
Month
Exposure Type:
Indicate A, B, C or D per Instructions above.
Frequency of Exposure During this Date Range:
Estimate either: Regular Exposure: OR Aggregate Exposure:
/
Year
To:
Month
/
Year
Man-Day(s) per Month
and
Hour(s) per Man-Day
Total Man-Day(s) per Instructions above
Date Range of Exposure: From:
Month
Exposure Type:
Indicate A, B, C or D per Instructions above.
Frequency of Exposure During this Date Range:
Estimate either: Regular Exposure: OR Aggregate Exposure:
/
Year
To:
Month
/
Year
Man-Day(s) per Month
and
Hour(s) per Man-Day
Total Man-Day(s) per Instructions above
Date Range of Exposure: From:
Month
Exposure Type:
Indicate A, B, C or D per Instructions above.
Frequency of Exposure During this Date Range:
Estimate either: Regular Exposure: OR Aggregate Exposure:
/
Year
To:
Month
/
Year
Man-Day(s) per Month
and
Hour(s) per Man-Day
Total Man-Day(s) per Instructions above
Date Range of Exposure: From:
Month
Exposure Type:
Indicate A, B, C or D per Instructions above.
Frequency of Exposure During this Date Range:
Estimate either: Regular Exposure: OR Aggregate Exposure:
/
Year
To:
Month
/
Year
Man-Day(s) per Month
and
Hour(s) per Man-Day
Total Man-Day(s) per Instructions above
8.
Describe the INJURED PARTY'S job duties: (attach additional pages if needed)
9.
Describe how the product identified in Question 3 of this Part was used at the site(s): (attach additional pages if needed)
10. If the exposure(s) listed in response to the above questions was/were at a construction site, estimate the percentage of time such exposure(s) occurred at residential and commercial sites: Residential:
Page 14
%
Commercial:
%
= 100 %
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PART 6: OCCUPATIONAL HISTORY
Provide the complete occupational history of the INJURED PARTY in chronological order, starting with the INJURED PARTY'S earliest employer. Include all jobs in which the INJURED PARTY worked at least a month, including any summer jobs, and conclude with any current employment. For Occupation Codes, use the Standard Occupational Classification Codes listed in Appendix C. For Industry Codes, use the Standard Industrial Classification Codes listed in Appendix D. If the INJURED PARTY has had more jobs than can fit on this page, copy the page before filling it out as many times as needed and complete the additional pages. 1. Employer Name: Employer Address:
Street
City
State
Zip
Dates Worked: From: Month Occupation Code: Industry Code:
/
Year
To: o: Month
/
Year
Specify if "Other": Specify if "Other":
2.
Employer Name: Employer Address:
Street
City
State
Zip
Dates Worked: From: Month Occupation Code: Industry Code:
/
Year
To: o: Month
/
Year
Specify if "Other": Specify if "Other":
3.
Employer Name: Employer Address:
Street
City
State
Zip
Dates Worked: From: Month Occupation Code: Industry Code:
/
Year
To: o: Month
/
Year
Specify if "Other": Specify if "Other":
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PART 7: OTHER EXPOSURE TO ASBESTOS
1.
a.
Was the INJURED PARTY exposed to asbestos outside the INJURED PARTY's occupation? Yes No
b.
Was the INJURED PARTY exposed to asbestos through another person (the "Source Individual")? Yes No
If you checked "Yes" to either Question 1(a) or Question 1(b), answer Questions 2 through 4. If you checked "Yes" to Question 1(b), additionally answer Questions 5 through 14. 2. Was the INJURED PARTY exposed to more than one asbestoscontaining product outside the INJURED PARTY'S occupation or through a Source Individual? If "Yes," copy this Part and complete the Part for each product. 3. Product Exposed To: (either directly or through Source Individual) Brand Name:
Yes
No
Manufacturer of Product: What is the basis for your belief that the exposure was to a DEBTOR'S product and not to another manufacturer's? Personal Recollection Other, Specify:
If you rely on another person for your belief that the INJURED PARTY was exposed to a DEBTOR'S product, provide that person's name:
Last
First
MI
If you rely on another person, has this person been deposed in any asbestos-related personal injury action?
Yes
No
If the other person has been deposed, attach to this Questionnaire a copy of any and all such depositions.
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PART 7: OTHER EXPOSURE TO ASBESTOS (Continued)
4.
Provide the date range and frequency of the INJURED PARTY's product exposure (either direct or through the Source Individual). If exposure was not continuous, provide all separate date ranges and frequencies of exposure. Start with the first date range of exposure and finish with the last date range of exposure. If there are more than four date ranges of exposure, copy this section before completing it and attach additional pages. Estimate the frequency of exposure as the average number of man-days per month and hours per man-day that the INJURED PARTY was exposed during the listed date range. If you are unable to do so, then estimate the aggregate number of man-days of exposure during the date range. One man-day of exposure equals eight hours of exposure. Frequency of Exposure During this Date Range: Date Range of Exposure: Estimate either: From: Month To: Month
/
Year
Regular Exposure: Man-Day(s) per Month
OR
Aggregate Exposure:
/
Year Date Range of Exposure:
and
Hour(s) per Man-Day
Total Man-Day(s) per Instructions above
Frequency of Exposure During this Date Range:
Estimate either: Regular Exposure: OR Aggregate Exposure:
From: Month To: Month
/
Year
Man-Day(s) per Month
/
Year Date Range of Exposure:
and
Hour(s) per Man-Day
Total Man-Day(s) per Instructions above
Frequency of Exposure During this Date Range:
Estimate either: Regular Exposure: OR Aggregate Exposure:
From: Month To: Month
/
Year
Man-Day(s) per Month
/
Year Date Range of Exposure:
and
Hour(s) per Man-Day
Total Man-Day(s) per Instructions above
Frequency of Exposure During this Date Range:
Estimate either: Regular Exposure: OR Aggregate Exposure:
From: Month To: Month 5.
/
Year
Man-Day(s) per Month
/
Year
and
Hour(s) per Man-Day
Total Man-Day(s) per Instructions above
Source Individual's Name (if you checked "Yes" to Question 1(b)):
Last
First
MI
6.
Was the Source Individual exposed to the product in more than one occupation? (Use the Standard Occupational Classification Codes listed in Appendix C.) If "Yes," copy this Part and complete the Part for each occupation. Source Individual's occupation during exposure: (Use Standard Occupational Classification Codes listed in Appendix C.) Source Individual's industry during exposure: (Use the Standard Industrial Classification Codes listed in Appendix D.)
Page 17
Yes
No
7.
Specify if "Other":
8.
Specify if "Other":
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PART 7: OTHER EXPOSURE TO ASBESTOS (Continued)
9.
Provide the date range and frequency of the Source Individual's product exposure in the occupation and industry listed in Questions 7 and 8. If the Source Individual's exposure was not continuous in the listed occupation and industry, provide all separate date ranges and frequencies of exposure. Start with the first date range of exposure and finish with the last date range of exposure. If there are more than four date ranges of exposure, copy this section before completing it and attach additional pages. For each date range of exposure, describe the exposure type as A, B, C, or D as follows: The Source Individual was: (A) a worker who personally worked with the product identified in Question 3 of this Part; (B) a worker in a room where other workers were personally working with the product identified in Question 3 of this Part; (C) a worker on a floor where other workers were personally working with the product identified in Question 3 of this Part; OR (D) a worker at a site where other workers were personally working with the product identified in Question 3 of this Part. Choose the category that best describes the Source Individual's type of exposure and choose only one category. The best category is the Source Individual's most typical or most usual form of exposure during the date range at issue. Estimate the frequency of exposure as the average number of man-days per month and hours per man-day that the Source Individual was exposed during the listed date range. If you are unable to do so, then estimate the aggregate number of man-days of exposure during the date range. One man-day of exposure equals eight hours of exposure. Date Range of Exposure: From:
Month
Exposure Type:
Indicate A, B, C or D per Instructions above.
Frequency of Exposure During this Date Range:
Estimate either: Regular Exposure: OR Aggregate Exposure:
/
Year
To:
Month
/
Year
Man-Day(s) per Month
and
Hour(s) per Man-Day
Total Man-Day(s) per Instructions above
Date Range of Exposure: From:
Month
Exposure Type:
Indicate A, B, C or D per Instructions above.
Frequency of Exposure During this Date Range:
Estimate either: Regular Exposure: OR Aggregate Exposure:
/
Year
To:
Month
/
Year
Man-Day(s) per Month
and
Hour(s) per Man-Day
Total Man-Day(s) per Instructions above
Date Range of Exposure: From:
Month
Exposure Type:
Indicate A, B, C or D per Instructions above.
Frequency of Exposure During this Date Range:
Estimate either: Regular Exposure: OR Aggregate Exposure:
/
Year
To:
Month
/
Year
Man-Day(s) per Month
and
Hour(s) per Man-Day
Total Man-Day(s) per Instructions above
Date Range of Exposure: From:
Month
Exposure Type:
Indicate A, B, C or D per Instructions above.
Frequency of Exposure During this Date Range:
Estimate either: Regular Exposure: OR Aggregate Exposure:
/
Year
To:
Month
/
Year
Man-Day(s) per Month
and
Hour(s) per Man-Day
Total Man-Day(s) per Instructions above
10. Source Individual's Social Security Number: *
Male Female
-
*
A confidentiality agreement limits disclosure and use of this social security number to persons involved in this case for purposes related to the case.
11. Source Individual's Gender: 12. Source Individual's Date of Birth:
/
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PART 7: OTHER EXPOSURE TO ASBESTOS (Continued)
13. If the Source Individual is living, provide that person's mailing address:
Street/P.O. Box
City
State
Zip
14. Source Individual's Relationship to INJURED PARTY: The INJURED PARTY is the Source Individual's:
(Spouse, Son, Daughter, etc.)
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PART 8: THE INJURED PARTY'S LAWSUITS AND BANKRUPTCY CLAIMS
A. LAWSUITS
1.
Has a lawsuit been filed by or on behalf of the INJURED PARTY for an asbestos-related personal injury? Yes No
If "Yes," complete the remainder of Part 8.A as instructed. If "No," continue to Part 8.B. 2. Has more than one lawsuit been filed by or on behalf of the INJURED PARTY for an asbestos-related personal injury? Yes No
If "Yes," copy Part 8.A and complete the Part for each lawsuit filed. 3. Case Caption:
4.
Case Number:
5.
Court Name:
6. 7.
Case Filing Date:
Month
/
Day
/
Year
Did the INJURED PARTY or the PERSONAL REPRESENTATIVE OF THE INJURED PARTY respond to any interrogatories in this lawsuit? Yes No
If "Yes," attach to this Questionnaire a copy of any and all such interrogatory responses. 8. Were the INJURED PARTY or the PERSONAL REPRESENTATIVE Yes No
OF THE INJURED
PARTY deposed in this lawsuit?
If "Yes," attach to this Questionnaire a copy of any and all such depositions. 9. a. b. Was the lawsuit dismissed? If "Yes," the basis for dismissal: Yes No
10. a. b.
Has a judgment or verdict been entered in this lawsuit?
Yes
No
If "Yes," against what defendant(s) and in what amount(s)? If against more than five defendants, copy this question before completing it and complete it for all defendants against whom a judgement or verdict was entered.
$
Defendant Amount
. . . . .
- <
$
Defendant Amount
$
Defendant Amount
$
Defendant Amount
$
Defendant
Page 20
Amount
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PART 8: THE INJURED PARTY'S LAWSUITS AND BANKRUPTCY CLAIMS (Continued)
A. LAWSUITS (Continued)
11. a. b. c.
Was a settlement agreement reached in this lawsuit? If "Yes," were any settlement agreement(s) subject to a binding confidentiality agreement?
Yes Yes
No No
If "Yes," for each settlement agreement that was the subject of a binding confidentiality agreement, provide the total number of defendant(s) who settled the lawsuit pursuant to the agreement, the aggregate settlement amount for the agreement, the lowest amount paid by a defendant under the agreement, and the highest amount paid by a defendant under the agreement. If there is more than one settlement agreement for the lawsuit, copy this question before completing it and attach additional pages. Total Number of Settling Defendant(s): Aggregate Settlement Amount:
$ $
Lowest Settlement Amount
. .
$
Highest Settlement Amount d.
.
If "No," or if some defendants settled the lawsuit without a confidentiality agreement, then identify the defendant(s) who settled the lawsuit without a confidentiality agreement and in what amount(s). If with more than five defendants, copy this question before completing it and complete it for all defendants.
$
Defendant Amount
. . . . .
$
Defendant Amount
$
Defendant Amount
$
Defendant Amount
$
Defendant e. Amount
If a settlement agreement was reached with US GYPSUM or another DEBTOR, have any settlement amounts been paid? Yes No
f.
If "Yes," by what DEBTOR(s) and in what amount(s)? If by more than two DEBTORS, copy this question before completing it and complete it for all DEBTORS who paid a settlement amount.
$
DEBTOR Amount
. .
$
DEBTOR Amount
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PART 8: THE INJURED PARTY'S LAWSUITS AND BANKRUPTCY CLAIMS (Continued)
B. BANKRUPTCY CLAIMS
1.
Has a claim been submitted by or on behalf of the INJURED PARTY for an asbestos-related personal injury in another bankruptcy case ("Other Bankruptcy") or against a trust established pursuant to a plan of reorganization or liquidation in another bankruptcy case ("Bankruptcy Trust")? Yes No
If "Yes," complete the remainder of Part 8.B as instructed. If "No," continue to Part 9. 2. Has more than one bankruptcy claim been filed by or on behalf of the INJURED PARTY for an asbestos-related personal injury? If "Yes," copy Part 8.B and complete the Part for each bankruptcy claim filed. 3. Other Bankruptcy or Bankruptcy Trust in which the claim was submitted: Yes No
4.
Date the claim was submitted:
Month
/
Day
/
Year
5.
Description of the claim:
6.
Did the INJURED PARTY or the PERSONAL REPRESENTATIVE OF THE INJURED PARTY submit any written claim, including but not limited to a proof of claim form, in the Other Bankruptcy or against the Bankruptcy Trust? Yes No
If "Yes," attach to this Questionnaire a copy of any and all such written claims. 7. a. Was the claim paid? Yes b. No
If "Yes," the payment amount:
$
8. a. Yes b. No
.
Was the claim dismissed or otherwise disallowed or not honored?
If "Yes," the basis for disallowance:
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PART 9: THE SOURCE INDIVIDUAL'S LAWSUITS AND BANKRUPTCY CLAIMS
A. LAWSUITS
If you answered "Yes" to Question 1(b) in Part 7 regarding the INJURED PARTY'S exposure to asbestos through a Source Individual, complete this Part as instructed. If you answered "No," continue to Part 10. 1. Has a lawsuit been filed by or on behalf of the Source Individual for an asbestos-related personal injury? Yes No
If "Yes," complete the remainder of Part 9.A as instructed. If "No," continue to Part 9.B. 2. Has more than one lawsuit been filed by or on behalf of the Source Individual for an asbestos-related personal injury? Yes No
If "Yes," copy Part 9.A and complete the Part for each lawsuit filed. 3. 4. 5. Case Caption: Case Number: Court Name:
6. 7.
Case Filing Date: Month
/ Day
/ Year Yes No
Did the Source Individual respond to any interrogatories in this lawsuit?
If "Yes," attach to this Questionnaire a copy of any and all such interrogatory responses. 8. Was the Source Individual deposed in this lawsuit? If "Yes," attach to this Questionnaire a copy of any and all such depositions. 9. a. b. Was the lawsuit dismissed? If "Yes," the basis for dismissal: Yes No Yes No
10. a. b.
Has a judgment or verdict been entered in this lawsuit?
Yes
No
If "Yes," against what defendant(s) and in what amount(s)? If against more than five defendants, copy this question before completing it and complete it for all defendants against whom a judgement or verdict was entered.
$
Defendant Amount
. . . . .
- <
$
Defendant Amount
$
Defendant Amount
$
Defendant Amount
$
Defendant
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Amount
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PART 9: THE SOURCE INDIVIDUAL'S LAWSUITS AND BANKRUPTCY CLAIMS (Continued)
A. LAWSUITS (Continued)
11. a. b. c.
Was a settlement agreement reached in this lawsuit? If "Yes," were any settlement agreement(s) subject to a binding confidentiality agreement?
Yes Yes
No No
If "Yes," for each settlement agreement that was the subject of a binding confidentiality agreement, provide the total number of defendant(s) who settled the lawsuit pursuant to the agreement, the aggregate settlement amount for the agreement, the lowest amount paid by a defendant under the agreement, and the highest amount paid by a defendant under the agreement. If there is more than one settlement agreement for the lawsuit, copy this question before completing it and attach additional pages. Total Number of Settling Defendant(s): Aggregate Settlement Amount:
$ $
Lowest Settlement Amount
. .
$
Highest Settlement Amount d.
.
If "No," or if some defendants settled the lawsuit without a confidentiality agreement, then identify the defendant(s) who settled the lawsuit without a confidentiality agreement and in what amount(s). If with more than five defendants, copy this question before completing it and complete it for all defendants.
$
Defendant Amount
. . . . .
$
Defendant Amount
$
Defendant Amount
$
Defendant Amount
$
Defendant e. Amount Yes f. No
If a settlement agreement was reached with US GYPSUM or another DEBTOR, have any settlement amounts been paid?
If "Yes," by what DEBTOR(s) and in what amount(s)? If by more than two DEBTORS, copy this question before completing it and complete it for all DEBTORS who paid a settlement amount.
$
DEBTOR Amount
. .
$
DEBTOR Amount
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PART 9: THE SOURCE INDIVIDUAL'S LAWSUITS AND BANKRUPTCY CLAIMS (Continued)
B. BANKRUPTCY CLAIMS
1.
Has a claim been submitted by or on behalf of the Source Individual for an asbestos-related personal injury in another bankruptcy case ("Other Bankruptcy") or against a trust established pursuant to a plan of reorganization or liquidation in another bankruptcy case ("Bankruptcy Trust")? Yes No
If "Yes," complete the remainder of Part 9.B as instructed. If "No," continue to Part 10. 2. Has more than one bankruptcy claim been filed by or on behalf of the Source Individual for an asbestos-related personal injury? Yes 3. No
Other Bankruptcy or Bankruptcy Trust in which the claim was submitted:
4. 5. 6.
Date the claim was submitted:
Month
/
Day
/
Year
Description of the claim: Did the Source Individual submit any written claim, including but not limited to a proof of claim form, in the Other Bankruptcy or against the Bankruptcy Trust? Yes No
If "Yes," attach to this Questionnaire a copy of any and all such written claims. 7. a. Was the claim paid? Yes b. No
If "Yes," the payment amount:
$
8. a. Yes b. No
.
Was the claim dismissed or otherwise disallowed or not honored?
If "Yes," the basis for disallowance:
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PART 10: CERTIFICATION THAT INFORMATION IS TRUE AND COMPLETE
Make sure that this Questionnaire is certified as true and complete by the CLAIMANT and by any attorney that the CLAIMANT has. Both the CLAIMANT (either the INJURED PARTY or the PERSONAL REPRESENTATIVE OF THE INJURED PARTY) and any attorney for the CLAIMANT must sign below. 1. Use the checklist below to indicate which document(s) you are submitting with this Questionnaire and which you seek reimbursement for. DEBTORS will reimburse your reasonable expenses incurred in copying documents that you submit. Attach to this Questionnaire a receipt that shows the copy costs you incurred. Medical reports or records regarding a diagnosis alleged in Part 2 Responses to interrogatories in lawsuits indicated in Parts 8 or 9 Radiographic evaluations, such as x-rays or CT scans Depositions in lawsuits indicated in Parts 4, 8, or 9 Pulmonary function test (PFT) reports, including spirogram tracings, FORCED VITAL CAPACITY (FVC), FORCED EXPIRATORY VOLUME (FEV1), TOTAL LUNG CAPACITY (TLC), and DIFFUSION CAPACITY (DLCO OR DCO) Written claims, including proof of claim forms, in another bankruptcy or against a bankruptcy trust indicated in Parts 8 or 9 Written evidence of the authority of the PERSONAL REPRESENTATIVE OF THE I NJURED P ARTY to act on behalf of the I NJURED P ARTY (if this Questionnaire is submitted by the PERSONAL REPRESENTATIVE) Death certificate (if the INJURED PARTY is deceased) Total amount of copy costs sought: A receipt showing copy costs is attached. 2. Complete and sign the Authorization for Release of Earnings Information and Employment Records From the Social Security Administration contained in Appendix A. A confidentiality agreement entered in this case limits disclosure and use of the records and information received from the Social Security Administration pursuant to the Authorization. See Instruction No. 11 on page 3. The executed release is attached. 3. I have reviewed the information submitted on this Questionnaire and all supporting documents submitted with it. I declare, under penalty of perjury, that, to the best of my knowledge, the information submitted is accurate and complete. Copy costs sought Copy costs sought Originals attached as required Copy costs sought
Copy costs sought
Copy costs sought
Copy costs sought
Copy costs sought
$
Amount
.
/
Month Day
/
Year
(Signature of CLAIMANT)
/
Month Day
/
Year
(Signature of CLAIMANT'S attorney, if any)
Review your Questionnaire to ensure that it is true and complete and that you have attached all supporting documentation. This Questionnaire is an official court document that may be used as evidence in any legal proceeding regarding your claim. The penalty for knowingly and fraudulently making a false statement under penalty of perjury is a fine of up to $500,000 or imprisonment for up to five years, or both.
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APPENDIX A AUTHORIZATION FOR RELEASE OF EARNINGS INFORMATION AND EMPLOYMENT RECORDS FROM THE SOCIAL SECURITY ADMINISTRATION AUTHORIZATION: I hereby authorize the Social Security Administration to furnish to the law firm of Cooley Godward LLP, its partners, employees and agents ("Cooley Godward"), any and all earnings information and employment records ("SSA Employment Records") pertaining to: Name: Other Name(s) Used (Including Maiden Name):
-
-
/
Date of Birth
/
Social Security Number
I hereby further authorize Cooley Godward to prepare and sign a Request for Social Security Earnings Information (Form SSA-7050-F4) on my behalf in order to permit Cooley Godward to request my SSA Employment Records from the Social Security Administration. I acknowledge that I was provided with a blank copy of a Request for Social Security Earnings Information form (Form SSA-7050-F4) for my reference. AUTHORIZED PERSONS AND ENTITIES: This release authorizes Cooley Godward to obtain, receive and use my SSA Employment Records in connection with the litigation entitled In re USG Corporation, United States District Court for the District of Delaware, Case Nos. 01-02094 (JKF), 04-1559 (JFC) and 04-1560 (JFC) ("USG Litigation"). A confidentiality agreement entered into by the parties in the USG Litigation provides that the following information may be disclosed only to persons involved in the case, that it will be held in strict in confidence by persons who receive it, and that it will be used only for purposes related to the case: (1) my social security number; (2) my SSA Employment Records; and (3) information contained in my SSA Employment Records when disclosed in conjunction with my name, address, or social security number. DURATION: This authorization shall become effective immediately and shall expire upon final resolution of the USG Litigation identified above. SIGNATURE:
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Signature Date
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If the Authorization is signed by a Personal Representative of the individual, a description of such representative's authority to act for the individual.
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APPENDIX B COMPANY HISTORY ABOUT PRODUCTS CONTAINING ASBESTOS
United States Gypsum Company is a subsidiary of USG Corporation. United States Gypsum Company was formed in 1901 and is in the business of manufacturing and selling building products. Some of the building products manufactured and sold by United States Gypsum Company from 1920 through 1978 contained asbestos. Products that may have contained asbestos during this period include some wall and ceiling plasters, spray fireproofing, fire-rated ceiling tiles, decorative textures, joint compound, and industrial insulation. Most of these products did not contain asbestos at all times from 1920 through 1978. No product contained asbestos as part of the product formulation after 1978. A list of trade names of products manufactured by United States Gypsum Company during the period from 1920 through 1978 that may have contained asbestos includes, but may not be limited to, the following:
A-B Tex Texture Paint ACOUSTONE 120 Ceiling Tiles ACOUSTONE 180 Ceiling Tiles AUDICOTE Acoustical Plaster Aggregated Spray Finish, White CHINA GLAZE Siding Column Fire Board Concrete Ceiling Texture DURABOND Joint Compound Exterior Texture Wallboard Finish Fire Door Coreboard Hi-LITE Acoustical Plaster IMPERIAL "QT" (Spray) Texture Finish KEMIDOL Joint Compound K-FAC 19 Block Insulation K-FAC Block Insulation MAYFAIR Shake Siding Multi-Purpose Texture Finish ORIENTAL Exterior Finish Stucco ORIENTAL Interior Finish PAC-TEX Texture Paint PERF-A-TAPE Joint Compound PYROBAR Mortar Mix USG "QT" Simulated Acoustical Spray Texture Ready-Mixed Imperial "QT" Simulated Acoustical Spray Texture RED TOP Acoustical Plaster RED TOP BONDCRETE Plaster-Basecoat RED TOP Cover Coat Finish Plaster RED TOP Firecode D Plaster RED TOP Firecode "V" Plaster RED TOP Gypsum Plaster RED TOP Patching Plaster RED TOP Sanded Wall Plaster RED TOP Strucolite Plaster RED TOP Trowel Finish RED TOP Wood Fiber Plaster REGENCY Shingles SABINITE Acoustical Plaster SHEETROCK Radiant Heat Filler-Machine Application SHEETROCK Radiant Heat Simulated Acoustical Texture Simulated Acoustical Spray Texture/Finish Special Texture Paint SPRAYDON Powercote SPRAYDON Standard A SPRAYDON Standard G STRUCTOLITE Plaster Superhard Spray Texture Finish SUPERTITE Roofing Products TEXOLITE Block Filler TEXOLITE Dry Fill TEXOLITE Drywall Surfacer TEXTONE Texture Finish THERMALUX Radiant Heating Panels USG Joint Compound Wainscoat Trowel Finish Plaster
United States Gypsum Company also manufactured other products in the following generic categories that may have contained asbestos: Adhesives Asbestos Board Asbestos Paper Insulating Cement Joint Compound Pipecovering Roofing Products Cement Siding Shingles
USG Corporation was formed in 1985 and is the parent company of various debtors in this chapter 11 proceeding. USG Corporation has never manufactured or sold any building products. Various subsidiaries of USG Corporation manufactured or sold building products that contained asbestos at various times in the past. L&W Supply Company, a subsidiary of USG Corporation, is a distributor of building materials manufactured by United States Gypsum Company and other companies. L&W Supply Company was created in 1971 as a subsidiary of United States Gypsum Company and, since 1985, has been a subsidiary of USG Corporation. In the 1970s, some of the products distributed by L&W Supply Corporation, primarily joint compound and roofing materials, contained asbestos. Since its formation in 1971, L&W Supply Company distribution centers have operated under different business names in different locations. A list of these business names is available on the USG claims website at http://www.usgclaims.com/ LandWbusiness_names.asp. Beadex Manufacturing, LLC, a subsidiary of United States Gypsum Company, manufactured and sold joint compound containing asbestos from 1963 through 1978. Distribution of products that contained asbestos is believed to have been limited to Washington, Oregon, Idaho, Alaska, and possibly Colorado. USG Interiors
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