Green Form (To Apply For Matrix Compensation Benefits)

GREEN FORM - Diet Drug Settlement Program Claim Form for Incremental Matrix Compensation Benefits. This Green Form should be used if you believe that you are entitled to Incremental Matrix Compensation Benefits under the Diet Drug Settlement Agreement with American Home Products Corporation. Matrix Compensation Benefits are described generally in the official notices authorized by the Court and in the “Settlement Matrix Compensation Benefits Guide for Physicians, Attorneys and Class Members,” which is an Appendix to this Form. Incremental Matrix Compensation Benefits mean the incremental dollar amount, if any, by which the Matrix Grid Amount for a higher Matrix Level for a Progression Matrix Level Condition exceeds the Matrix payment previously made to or on behalf of the Eleventh Amendment Class Member, pursuant to Section IV.C.3 of the Settlement Agreement. There are three parts to this Green Form and an informational Appendix: Part I: Matrix Compensation Benefits Claim Form to be completed by Claimant or Claimant’s Representative. Part II: Doctor’s Evaluation Form to be completed by a Board-Certified Physician. Part III: Claimant’s Lawyer Statement to be completed if Claimant is represented by an Attorney. Appendix: Settlement Matrix Compensation Benefits Guide for Physicians, Attorneys and Class Members. This Green Form must be submitted to the Claim Administrator no later than four years from the date on which the Claimant was first diagnosed as having the Progression Matrix Level Condition upon which the Claim for Incremental Matrix Compensation Benefits is based. www.FormsWorkflow.com