Section 1.B: If you are filing a PI Claim due to another’s death from use of opioids, or you are completing this form as the representative of an individual with a claim due to another’s death from use of opioids, please fill out the information below.

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PRESCRIBED MEDICATION - Identify any of the following Purdue-brand opioids that the person whose opioid use is the subject of your Non-NAS PI Claim was prescribed. Include evidence of the prescriptions when submitting this Claim Form. (A claim may qualify without prescription if the person who used opioids was a minor at the time the use began.)

SECTION 4.B: Identify any of the following Medication Assistance Treatment (MAT) drugs prescribed to the person whose opioid use is the subject of your Non-NAS PI Claim. Include evidence of the prescriptions when submitting this Claim Form.(If you selected Easy Payment, SKIP this Section.)

SECTION 4.C: Identify any of the following medications provided to the person whose opioid use is the subject of your Non-NAS PI Claim during or after an opioid overdose. Include evidence of the prescriptions or administration when submitting this Claim Form. (If you selected Easy Payment, SKIP this Section.)

INJURIES SUFFERED BY THE DECEASED - INJURIES SUFFERED BY THE PERSON WHO USED OPIOIDS - SECTION 5.A: Please mark all that are applicable to your claim.

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MEDICAL PROVIDER INFORMATION - SECTION 7.A: In this section, please identify information for the medical providers (prescribing doctors and pharmacies) who prescribed opioids to the person whose opioid use is the subject of your Non-NAS PI Claim:

Medical Liens

Authorization to Disclose Health Information

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HEIRSHIP DECLARATION / SWORN DECLARATION ( SIGNATORY IS EXECUTOR UNDER DECEDENT’S LAST WILL AND TESTAMENT) - I. DECEDENT (DECEASED) INFORMATION

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II. PI CLAIMANT INFORMATION

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    III. HEIRS AND BENEFICIARIES OF DECEDENT

    Use the space below to identify the name and address of all persons who may have a legal right to share in any settlement payment on behalf of the claim of the Decedent. Also, state if and how you notified these persons of the settlement, or the reason they cannot be notified.

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