Diffuse Mesothelioma Payment Scheme

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.


    The Applicant
    Please provide details of the person making the application to the scheme







    The person with Diffuse Mesothelioma
    Please provide details of the person who developed Diffuse Mesothelioma





    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.





    Diagnosis



    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.




    Your Solicitor's Details* *If applicable









    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.

    Payment Method
    Should you be entitled to a payment under this scheme, please indicate your preferred method of payment.


    chequebacs

    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.



    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.


    Dependant 1














    Dependant 2














    Dependant 3














    Dependant 4














    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




    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.