POM Forms


To file your POM form, select the class that best describes your claim. Complete all sections of the form including signature and return to the Settlement Facility.

Class 5

Applies to claimants who are a United States citizen or a resident alien of the greater U.S. or whose claim arises from a medical procedure performed in the greater U.S.

Class 5 POM Form - English
English

 

Class 6.1

Applies to claimants who are not a United States citizen or a resident alien of the greater U.S. and whose claim arises from a medical procedure performed outside the greater U.S. Foreign claimants are categorized based on their country of residence. For more information on foreign claimant class assignment, refer to Annex A To The Settlement Facility and Fund Distribution Agreement (Annex A), Section 6.05, (h) (i)

 

Class 6.1 POM Claim Form - English
English
Class 6.1 POM Claim Form - Dutch
Dutch/Nederlands
Class 6.1 POM CLaim Form - English
French/Français
Class 6.1 POM Form - Swedish
Swedish/Svenska
Class 6.1 POM Form - German
German/Deutsch
 
 

 

Class 6.2 

Applies to claimants who are not a United States citizen or a resident alien of the greater U.S. and whose claim arises from a medical procedure performed outside the greater U.S. Foreign claimants are categorized based on their country of residence. For more information on foreign claimant class assignment, refer to Annex A To The Settlement Facility and Fund Distribution Agreement (Annex A), Section 6.05, (h) (i)

Class 6.1 POM Form - English
English
Class 6.1 POM Form - Portuguese
Portuguese/Português
Class 6.2 POM Form - Spanish
Spanish/Español