Use these forms to complete the Settlement Program process. More information on the Settlement Program process can be found at the Settlement Agreement tab, and in the Settlement Agreement.
If you are represented by an attorney for your Durom Cup claim, your attorney is responsible for submitting these documents for you. Do not submit these forms on your own behalf if you are represented by an attorney.
Durom Cup Inventory Registration Form (Exhibit A)
Unrepresented Durom Cup Claimant Registration Form (Exhibit B)
Categorization and Award Amount Form (Exhibit C)
Extraordinary Loss or Injury Claim Form (Exhibit D)
Mediation Request Form (Exhibit F)
Form W-9: Request for Taxpayer Identification Number and Certification
Sample Stipulation of Dismissal with Prejudice
Affidavit of Medicare Beneficiary Status and CMS Medicare Beneficiary Status Form (Plaintiff)
Spouse’s Affidavit of Medicare Beneficiary Status and CMS Medicare Beneficiary Status Form (Plaintiff)
Affidavit of Medicare Beneficiary Status and CMS Medicare Beneficiary Status Form (Claimant)
Spouse’s Affidavit of Medicare Beneficiary Status and CMS Medicare Beneficiary Status Form (Claimant)