Claim Requirement

2

Claim Requirements

1. Regarding information about the claimant

Name

Mailing address

Legal residence address

Date of birth

Place of birth

Merchant mariner license or document number

Social Security Number

2. Circumstances describing the basis for the alleged incident

Name of vessel where employed and incident occurred

Location of vessel at time of incident

Location of incident aboard vessel (if applicable)

Time of incident: year, month, day, hour (in local time)

Narrative of the facts and circumstances surrounding the incident;

Name(s) of person(s) who can provide factual information about incident and its consequences

3. Allocation of dollar damages claimed (the dollar amount the claim is for)

Past loss of earnings or earning capacity

Future loss of earnings or earning capacity

Medical expenses paid out-of-pocket

Pain and suffering

Any other loss arising out of the incident

D. Medical illness or injury records

Hospital and physicians’ medical and clinical records describing illness, injury, or death

Medical records release providing written authorization for MARAD to obtain historical medical records

Name(s) and address(es) of hospital(s) and/or treating physician(s)

Certificates of Discharge for current and previous two years’ employment history as a seafarer

Current and two previous calendar years of W-2, and income tax filing to show separate historical employment earnings in occupational categories as both a seafarer and non-seafarer (if any)

Copies of medical not-fit-for-duty status reports and fit-for-duty declaration

E. Information about reshipment status and non-seafarer employment (if any) subsequent to medical medically-determined recovery from illness or injury

Location and date of registry for reshipment

Date of reshipment and identity of employer and vessel

If not reshipped, and employed in a non-seaman occupation, identity of employer, salary and date employed