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PERSONAL INFORMATION OF CLAIMANT

Section 1.A: If you hold a PI Claim arising from your own use of opioids(or if such holder is alive and you are completing this form as his/her representative), then the term “Claimant” in this Claim Form refers to the person who used opioids, whether that is you or the person you represent. 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.)

Please Select All That Apply

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.)

Please Select All That Apply

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.)

Select All That Apply

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

SECTION 8.A: Did any insurance company pay for medical treatment for the opioid-related injuries that gave rise to your Non-NAS PI Claim?