Forms
 
Click the links below to view, download or print these forms:
Registration Materials:
1. Registration Form
2. Registration Form Instruction Booklet
3. Opt Out Revocation Request Form
4. Sworn Statement in Support of Challenge to Registration Determination (SWS-1)
Centralized Process for Representative Claimant Appointment:
1. Documents Required for Appointment of Representative Claimant
2. Petition for Appointment of Representative Claimant
3. Proposed Representative Claimant Declaration for a Deceased Retired NFL Football Player
4. Proposed Representative Claimant Declaration for a Legally Incapacitated or Incompetent Retired NFL Football Player
5. Instructions for Representative Claimants on Completing the Centralized Process Forms
Monetary Awards for Retired NFL Football Players and Representative Claimants:
1. Claim Form for Retired NFL Football Players and Representative Claimants
2. Instructions for Completing the NFL Concussion Settlement Claim Form
3. Monetary Award Claim Package HIPAA Authorization Form
4. MAF Diagnosing Physician Certification Form
5. Pre-Effective Date Diagnosing Physician Certification Form
6. MAF Claim Package Kit (all of 1-5 in one set)
7. Diagnosing Physician Sworn Statement: Inability to Provide a Diagnosing Physician Certification for a Deceased Retired NFL Football Player Without Medical Records (SWS-2)
8. Third-Party Sworn Statement: Functional Impairment (SWS-3)
9. Sworn Statement by Retired NFL Football Player: Reasons for No Objective Evidence of Eligible Season(s) (SWS-4)
Derivative Claimant Awards:
1. Derivative Claim Form
2. Instructions for Completing the Derivative Claim Form
3. Derivative Claimant HIPAA Authorization Form
Centralized Process for Derivative Claimant Representative Appointment:
1. Documents Required for Appointment of Derivative Representative Claimant
2. Petition for Appointment of Derivative Claimant Representative
3. Proposed Derivative Claimant Representative Declaration for a Minor Derivative Claimant
4. Proposed Derivative Claimant Representative Declaration for a Legally Incapacitated or Incompetent Derivative Claimant
5. Instructions for Derivative Claimant Representatives on Completing the Centralized Process Forms
Other Documents:
1 Authorization for Release of Claims Information
2. Request for Change in Representation Status
3. BAP HIPAA Form
Payment Documents:
1 Unrepresented Settlement Class Member Payment Election Form
2. Law Firm Payment Election Form
3. Form W-9
1-855-887-3485
ClaimsAdministrator@NFLConcussionSettlement.com
P.O. Box 25369 Richmond, VA 23260