Claim Forms for Class Action Settlement Benefits

This Orange Form, the Affected Product Revision Surgery (APRS) Benefit Claim Form, is to be completed by a Class Member who is registering for settlement benefits as an Affected Product Recipient (APR), and who (1) has been implanted with an Affected Product (Sulzer Inter-Op™ Shell, Sulzer Reprocessed Inter-Op™ Shell, or Sulzer Tibial Baseplate), and (2) has undergone an Affected Product Revision Surgery (APRS). If the APR has been implanted with more than one Affected Product, a separate Claim Form must be completed for each implanted Affected Product. APRS Claimants who wish to participate in the Guaranteed Payment Option (GPO) must make that election on this Orange Form.

This Blue Form, the Unrevised Affected Product Recipient (APR) Benefits Claim Form, is to be completed by a Class Member who is registering for settlement benefits as an Affected Product Recipient (APR), and who (1) has been implanted with an Affected Product (a Sulzer Inter-Op™ Shell or Sulzer Tibial Baseplate, but NOT a Reprocessed Inter-Op™ Shell), and (2) has not undergone an Affected Product Revision Surgery (APRS) to remove the Affected Product. If the APR has been implanted with more than one Affected Product, a separate Claim Form must be completed for each implanted Affected Product.

This Green Form, the Extraordinary Injury Fund (EIF) Benefits Claim Form, is to be completed by a Class Member who is registering for settlement benefits from the EIF as an Affected Product Recipient (APR) who was implanted with a Sulzer Inter-Op™ Shell, Sulzer Reprocessed Inter-Op™ Shell, or a Sulzer Tibial Baseplate. To qualify for benefits from the EIF, a timely-filed Blue or Orange Form (whichever is appropriate) must be submitted in addition to this Green Form. The Green Form and the Orange or Blue Form do not need to be filed simultaneously, but all Forms must be filed within the time limits of the Settlement Agreement. If the APR has been implanted with more than one Affected Product, a separate Claim Form must be completed for each implanted Affected Product.

This Red Form, the Uninsured Affected Product Recipient Benefits Claim Form, is to be completed ONLY by a Class Member who is registering for settlement benefits as an Uninsured Affected Product Recipient (Uninsured APR) who (1) was implanted with a Sulzer Inter-Op™ Shell, Sulzer Reprocessed Inter-Op™ Shell, or a Sulzer Tibial Baseplate, and (2) has undergone an Affected Product Revision Surgery (APRS) for the Affected Product. To qualify to receive benefits, the Class Member must have previously submitted or must simultaneously submit an Orange Form. If the APR has been implanted with more than one Affected Product, a separate Claim Form must be completed for each implanted Affected Product.

The Yellow Form, the Derivative Claimant Benefit Form, is to be completed ONLY by a Class Member who is registering for settlement benefits as a Derivative Claimant (Spouse or Significant Other) of an Affected Product Recipient (APR) who was implanted with a Sulzer Inter-Op™ Shell, a Sulzer Reprocessed Inter-Op™ Shell, or a Sulzer Tibial Baseplate. If the APR has been implanted with more than one Affected Product, a separate Claim Form must be completed for each implanted Affected Product.

For an Affected Product Recipient (APR) to qualify for certain benefits, this Physician Declaration Form must be completed by the APR’s treating physician to certify that an APR has or had a particular medical condition related to the Affected Product. These medical conditions are set forth in the various Claim Forms, and include surgical removal and/or replacement of an Affected Product for a reason other than trauma (Affected Product Revision Surgery or APRS).

Application for Payment of Coinsurance and/or Deductible Payments From Class Members' Class Action Settlement Benefits

Third Party Payor Settlement and Release Agreement