Purdue Personal Injury Trust

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If you are represented by a lawyer in connection with your Purdue opioid-related personal injury, before you submit a Claim Form, contact the lawyer you hired to represent you in connection with your Purdue opioid-related personal injury and check that your lawyer has not already submitted a Claim Form on your behalf.

WHO SHOULD CONSIDER SUBMITTING

 A NON-NAS PI CLAIM FORM?

Non-NAS PI Claim Forms should be submitted by individuals who first filed a Proof of Claim against one of the Debtors in the Purdue Chapter 11 Bankruptcy case on or before September 21, 2021, and whose claim for personal injury arose from the their own use of a Purdue prescribed Qualifying Opioid, or, if the injured party is deceased, the Non-NAS Claim Form should be filed by the legal heir or legal representative authorized to file a claim on behalf of the deceased for the deceased’s own use of a Purdue prescribed Qualifying Opioid. 

ELIGIBILITY AND CLAIM REQUIREMENTS

In order to be eligible for a Distribution from the PI Trust for a Non-NAS PI Channeled Claim, a claimant will, among other things, be required to:

  1. Hold such Non-NAS PI Channeled Claim against one or more Debtors;
  2. Provide proof demonstrating usage prior to the September 15, 2019 Petition Date of a prescribed Qualifying Opioid listed in Exhibit C to the TDP and also listed on Pages 9 and 10 of the Form; and
  3. Have timely filed an individual personal injury Proof of Claim for such Non-NAS PI Channeled Claim against one or more Debtors in the Chapter 11 Cases.

ADDITIONALLY, each Holder of a Non-NAS PI Claim seeking an Award from the PI Trust must complete, sign, and submit the following documents so that they are received on or before July 28, 2025, at 11:59 p.m. (Eastern Time) (the “PI Claims Deadline”):

  1. The Non-NAS PI Claim Form;
  2. The applicable HIPAA consent form on Pages 11 and 12 of the Non-NAS PI Claim Form; and
  3. To the extent the Non-NAS PI Channeled Claim concerns the injuries of a decedent of the Holder of such Claim, the Heirship Declaration, or valid estate documents authorizing the Holder of the Claim to act on behalf of the decedent’s estate.

FAILURE TO SUBMIT THIS NON-NAS PI CLAIM FORM ALONG WITH THE REQUIRED INFORMATION OUTLINED UNDER THE ELIGIBILITY SECTION ABOVE SO THEY ARE RECEIVED BY JULY 28, 2025, AT 11:59 P.M. (EASTERN TIME) IN ACCORDANCE WITH THE NON-NAS PI TDP MAY RESULT IN THE NON-NAS PI CLAIM POTENTIALLY BEING THE SUBJECT OF AN OBJECTION, DISALLOWANCE, OR DENIAL AND NOT RECEIVING ANY DISTRIBUTION.

Submitting this Non-NAS PI Claim Form does not guarantee that your Non-NAS PI Claim will be Allowed or that you will receive payment from the PI Trust.

IMPORTANT DOCUMENTS TO REVIEW

BEFORE FILING A NON-NAS PI CLAIM FORM

Non-NAS PI Trust Distribution ProceduresDownload

Non-NAS PI Claim FAQs (Coming Soon)

Non-NAS PI Claim Form and Instructions, Including HIPAADownload
Heirship DeclarationDownload

INSTRUCTIONS ON HOW TO COMPLETE

 A NON-NAS PI CLAIM FORM

The below provides instructions on how to complete the Non-NAS PI Claim Form.

Step 1: Personal Information of PI Claimant – Part 1 of the Claim Form

Fill in the Claimant’s personal identification information.

Section 1.A is to be completed if the injury arises from your own use of a Qualifying Opioid or if you are the representative of another living person who used a Qualifying Opioid.

Section 1.B is to be filled out if the injury arises from the use of a Qualifying Opioid by a deceased individual.

Step 2: Prescribed Medications – Part 2 of the Claim Form

Check the box or fill in the name of any of the brand name or generic Qualifying Opioids that were prescribed and used by you or the opioid user on whose behalf you are submitting this claim.

Indicate the first use of the qualifying opioids identified in the section.

This section also details the types of Evidence you will be required to submit in order to show use of a Qualifying Opioid.

Step 3: Tier Designation – Part 3 of the Claim Form

Check the tier that applies to the claim you are filing. ONLY SELECT ONE TIER.

Tier 1 is to be selected if the evidence demonstrates use of a Qualifying Opioid for six or more months (180 days or more) for a period prior to September 15, 2019.

Tier 2 is to be selected if the evidence demonstrates use of a Qualifying Opioid for less than six months (less than 180 days) for a period prior to September 15, 2019.

Step 4: Medical Liens – Part 4 of the Claim Form

Mark “YES” or “NO” for each section (Medicare, Medicaid, Tricare, Veterans Administration Medical Benefits, and Private Insurance Provider(s)) to indicate whether you had Medicare, Medicaid, Tricare, Veterans Administration Medical Benefits, and/or Private Insurance over the last twenty (20) years.

If “YES” is marked for any section, fill in the remaining blanks in that section.

Step 5: Signature – Part 5 of the Claim Form

Fill in the name, email address, and phone number of the person signing this form.

If you are signing this form as the claimant or as the representative of the claimant, sign in the appropriate signature block.

If you are signing this form as counsel of record (the attorney) for the claimant or representative, sign in the appropriate signature block.

Step 6: Confirmation of Submission of Required Proof of Usage of a Qualifying Prescribed Opioid – Part 5 of the Claim Form

            Check the box that indicates the status of your required evidence.

If you are including the required evidence of a Qualifying Opioid prescription with the current claim submission, please check the box indicating so.

If your evidence of a Qualifying Opioid prescription was previously submitted with your Proof of Claim filed in the Debtor’s Chapter 11 Cases, please check the box indicating so.

Step 7: HIPAA Release Form

Complete and sign this entire form using information for the Injured Party.

Please note that the social security number of the Injured Party is required.

HOW TO SUBMIT A NON-NAS PI CLAIM FORM

You can submit the Non-NAS PI Claim Form one of the following ways:

  1. Submit the Non-NAS PI Claim Form and supporting documentation, including the required evidence of a Qualifying Opioid, on this Website by clicking HERE; or
  2. Print the Non-NAS PI Claim Form by clicking HERE, then complete, sign, and return the Non-NAS Claim Form, including all supporting documentation and required evidence of a Qualifying Opioid by:
  1. e-mail to purduepitrust@purduepitrust.com,
  2. mail to Purdue PI Trust, P.O. Box 361930, Hoover, Alabama, 35236-1930, or
  3. fax to Purdue PI Trust at 205-716-2364.

THE DEADLINE TO SUBMIT A NON-NAS PI CLAIM FORM, INCLUDING ALL REQUIRED DOCUMENTATION AND SIGNATURES, IS JULY 28, 2025, by 11:59 P.M. (EASTERN TIME).

QUESTIONS?

Please check the FAQs posted above or on this Website under the “FAQs” tab for answers to frequently asked questions.

If you have additional questions not answered in the FAQs, Non-NAS PI Claims Tab, or the Pleadings and Important Documents tab, contact the Claims Administrator: