Contact Form Test Application Form When submitting your application to the Diffuse Mesothelioma Payment Scheme you must also provide copy documentation in support. Specifically, we require evidence detailing the sufferer's entire employment history, evidence confirming diagnosis (this would normally be a letter from a registered medical practitioner, e.g. the sufferer's GP), and a witness statement. Are you: A Person With Diffuse MesotheliomaA dependant of a deceased person with Diffuse MesotheliomaA family member because the sufferer is too ill to applyA solicitor acting on behalf of the applicant The Applicant Please provide details of the person making the application to the scheme First Name (required) Last Name (required) Gender (required) MaleFemaleCustomRather Not Say Address City Postcode Country List All CountriesEuropeAmericasAsiaOceania The person with Diffuse Mesothelioma Please provide details of the person who developed Diffuse Mesothelioma First Name Last Name Gender (required) MaleFemaleCustomRather Not Say National Insurance Number Date of Birth Date of Death Employment History Please provide the full employment history of the person with Diffuse Mesothelioma, starting with the oldest first. We require this information in order to establish that exposure to asbestos was caused at work through employer negligence, and to rule out the possibility of there being a claim for civil compensation. If there are any gaps in employment history or in the sufferer's employment, please explain and give brief circumstances (e.g. “Apprenticeship in 1961-62, details of employer not known” or “1972-1973 took career break due to ill health”). Please provide supporting evidence. How many jobs has the person with Diffuse Mesothelioma Had? List numbers to 1212 G1 - Month and Year of start of employment gap (MM/YYYY) G1 - Month and Year of end of employment gap (MM/YYYY) G1 - Please explain and give brief circumstances (e.g. “Apprenticeship in 1961-62, details of employer not known” or “1972-1973 took career break due to ill health”). Please attach the sufferer's evidence of employment history Evidence to follow in paper format via the postal service Diagnosis Date of Diagnosis Age at date of Diagnosis Do you have evidence of diagnosis? This would normally be a letter from a registered medical practitioner e.g. the sufferer's GP. Please attach the sufferer's evidence of Diagnosis Evidence to follow in paper format via the postal service Previous Claims and Payments This is a scheme of last resort. If you have been able to access compensation from a responsible party, you will not be eligible for a scheme payment. If you have received a payment from a state funded scheme of support, you may still be eligible for the Diffuse Mesothelioma Payment Scheme, although the earlier payment would be recovered from any DMPS payment. Have you been paid any compensation in respect of the Diffuse Mesothelioma? For example: compensation awarded by the court an out of court settlement compensation from an employer payment from the Armed Forces Compensation Scheme. Have you been paid any compensation in respect of Diffuse Mesothelioma? YesNo Are you waiting to hear about any compensation in respect of Diffuse Mesothelioma? YesNo Have you previously made a claim for compensation that was unsuccessful? YesNo Have you made a claim under the Pneumoconiosis etc (Workers’ Compensation) Act 1979 or the Child Maintenance and Other Payments Act 2008 in respect of the Diffuse Mesothelioma? YesNo Your Solicitor's Details* *If applicable Solicitors Firm Name Handling Solicitor's Name Solicitors Address City Country Postcode Solicitors Email Address Solicitors Phone Number Solicitor Reference Number Further Information Required In order to assess your eligibility for a payment, please provide the following information when submitting your application form. An application submitted without the following will be considered incomplete, and we will contact you requesting the required information. This could delay your application. If you have already contacted a solicitor regarding your application, it is likely that your solicitor took a witness statement from you. If you are not using a solicitor the witness statement should provide details of where you were working, how you were exposed, details of any witnesses and other evidence to support your case. Please attach a witness statement Evidence to follow in paper format via the postal service Payment Method Should you be entitled to a payment under this scheme, please indicate your preferred method of payment. Method chequebacs If you are an eligible dependant, or acting on behalf of the person who is/was diagnosed with Diffuse Mesothelioma, please confirm the names of the persons to which payment is to be made. Please note if you wish to be paid by BACS your bank account details will be required and the following section should be completed. Once a payment has been made to this account, the scheme has discharged its liability to make you a payment. If you wish to be paid by cheque, your bank details will not be required. Name of Bank Account Holders name Account Sort Code Account Number Additional Dependants If you are a dependant making an application, and there are additional dependants, please provide their details here. If there is more than one eligible dependant, the payment will be split equally between them. Should the dependants decide the payment should be split differently the dependants can agree amongst themselves after payment has been made. How many dependants do you have? OneTwoThreeFour Dependant 1 D1 - Name of Dependant D1 - Relationship to Applicant D1 - Address D1 - City D1 - Country D1 - Postcode D1 - Date of Birth Dependant 2 D2 - Name of Dependant D2 - Relationship to Applicant D2 - Address D2 - City D2 - Country D2 - Postcode D2 - Date of Birth Dependant 3 D3 - Name of Dependant D3 - Relationship to Applicant D3 - Address D3 - City D3 - Country D3 - Postcode D3 - Date of Birth Dependant 4 D4 - Name of Dependant D4 - Relationship to Applicant D4 - Address D4 - City D4 - Country D4 - Postcode D4 - Date of Birth Declaration I declare that the information I have given on this form and in the supporting evidence is correct and complete as far as I know and believe. I understand that if I knowingly give any information that is incorrect or incomplete, I may be liable to prosecution or other action, and my application may be invalidated. I understand that failing to provide all the requested information can delay my application being processed. I understand that completing this section will be taken as my signature. I have read and agree to the above declaration Signature (must match your Title, Forename and Surname; not case-sensitive) Copy Date If you are signing on behalf of the applicant, please state your name and your relationship to the applicant If you are signing on behalf of the applicant, please state your name and your relationship to the applicant Should you fail to complete any element of this application form your application will be put on hold until such information is provided. If you need additional help or advice in completing this form, please contact DMPS@topmarkcms.com or telephone 0330 058 3930 between the hours of 9am to 5pm Monday to Friday. How did you hear about the scheme? NewsTwitter/FacebookGoogle Search.gov.ukSupport GroupOther Δ
