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Shook & FletcherAsbestos Settlement TrustProof of Claim FormSend Claims to:Shook & Fletcher Asbestos Settlement Trustc/o MFR Claims Processing, Inc.115 Pheasant RunSuite 112Newtown, PA, 18940(215) 702-8033Instructions for the Claim FormComplete this claim form as thoroughly and accurately as possible. Please note that this claimform will not be accepted or processed unless the certification is executed in Section G below.Please type or print neatly. Should there be insufficient space to list all relevant information,please attach additional sheets. In addition to filing the forms that follow, please ensure thefollowing are enclosed, if applicable:- Death Certificate (if applicable)- Certificate of Official Capacity (if personal representative is filing form)- Medical records as requested in instructionsBy completing this form, the claimant agrees to provide such supporting documentation as maybe requested by the Trust in respect of such claimant’s claim.Plaintiff Law Firm Contact InformationFirm NameAttyName PhonePara/AdminName PhoneAddressEmailFax9178961v2
Section ASpecial Claims Status(See Claims Resolution Procedures, SECTION V)Extraordinary (Section 5.3(a))Exigent Hardship (Section 5.3(b))(Must also undergo IndividualReview)Derivative (Section5.4)Individual Review (Section 5.2(f))(For Individual Review, submit 100.00 fee via check payable tothe Shook & Fletcher AsbestosSettlement Trust)Section BInjured PartyName:FirstMiddleLastSocial Security Number: - -Date of Birth:MonthDayYearAddress (If Living):StreetCity9178961v2StateZip
Section CIf Injured Party is DeceasedDate of Death:Personal Rep Info:Name:FirstMiddleLastSocial Security Number: - -Address:StreetCitySection DStateZipLawsuit against Shook & Fletcher Insulation Co. or any otherProtected Party1Suit Filed?YesNoIf Yes:Date FiledMonth1DayYear“Protected Party” is defined in that certain Second Amended Glossary of the Terms for the Plan ofReorganization under Chapter 11 of the United States Bankruptcy Code for Shook & Fletcher InsulationCo. (the “Glossary”) as “any of the following parties: (a) the Debtor, Reorganized Shook & Fletcher, Shook& Fletcher Supply, the Asbestos Claimants Committee, Claimants’ Counsel, the Futures Representative,and the TAC, and any of their present, former and post-Confirmation Date Affiliates, officers, directors,shareholders, agents, employees, members, representatives, advisors, financial advisors, accountants andattorneys; (b) the Trust, and any of its trustees, officers, directors, agents, employees, representatives,advisors, financial advisors, accountants and attorneys; (c) the Pre-Petition Trust, and any of its trustees,officers, directors, agents, employees, representatives, advisors, financial advisors, accountants, andattorneys; (d) any Entity that, pursuant to the Plan or after the Confirmation Date, becomes a direct orindirect transferee of, or successor to, Reorganized Shook & Fletcher; and (e) each Settling AsbestosInsurance Company.” Any capitalized but undefined term used in the preceding sentence is defined in theGlossary. Copies of the Glossary are available from the Trust upon written request.9178961v2
State/JurisdictionDocket #Suit Dismissed Against Protected Party?YesNoIf Yes:Date DismissedMonthDayIf the suit has been dismissed, please submit proof of suchdismissal with this Claim Form.Section EAsbestos Related InjuryDate Of Diagnosis(Month/Day/Year)Disease Claimed:9178961v2MesotheliomaLung CancerOther CancerNon MalignantYear
Section FExposureAll Exposure Claimed As to Shook and Fletcher(Attach additional pages as necessary)1) FromMonthYearToMonthYearLocation of ExposureJobsiteCityStateOccupationEmployer2) FromMonthYearToMonthYearLocation of 2
3) FromMonthYearToMonthYearLocation of ExposureJobsiteCityStateOccupationEmployerSection G. Certification. The following certification must be executed before this Proofof Claim will be accepted or processed.2Attorney CertificationThe undersigned certifies, under penalty of perjury, as follows: I am authorizedto file this claim form; I, or other trained personnel within my firm, have reviewed theinformation submitted on this claim form and all documents submitted in support of thisclaim; and to the best of my knowledge, based on policies and procedures adopted andimplemented by my firm concerning claims processing, the information submitted is true,accurate and complete, and/or the information is included within the claimant’s file and isderived from information provided by the claimant, one or more of the claimant’s coworkers or the claimant’s medical experts.By (signature):Name (printed):Firm:2Note: If you are a claimant or personal representative filing this proof of claim form without an attorney,please contact MFR Claims Processing, Inc. using the contact information on the first page of this form orby email at shookinquiries@mfrclaims.com to request a claimant certification or personal representativecertification, as applicable.9178961v2
Shook & Fletcher Asbestos Settlement Trust c/o MFR Claims Processing, Inc. (215) 702-8033 Instructions for the Claim Form Complete this claim form as thoroughly and accurately as possible. Please note that this claim form will not be accepted or processed
