Seamen's Claims, Administrative Action and Litigation

OMB # 2133-0522
Expiration Date: 11/30/2021
A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure
to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information
displays a current valid OMB Control Number. The OMB Control Number for this information collection is 2133-0522. Public reporting for this
collection of information is estimated to be approximately 12.5 hour per response, including the time for reviewing instructions, completing
and reviewing the collection of information. All responses to this collection of information are required to obtain and/or retain benefits. Send
comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden
to: Information Collection Clearance Officer, Maritime Administration, MAR-390, 1200 New Jersey Avenue, SE, Washington, DC 20590.

Claim Requirements
A. Regarding information about the claimant
Name
Mailing address
Legal residence address
Date of birth
Place of birth
Merchant mariner license or document number
Social Security Number
B. Circumstances describing the basis for the alleged incident
Name of vessel where employed and incident occurred
Location of vessel at time of incident
Location of incident aboard vessel (if applicable)
Time of incident: year, month, day, hour (in local time)
Narrative of the facts and circumstances surrounding the incident;
Name(s) of person(s) who can provide factual information about incident and its
consequences
C. Allocation of dollar damages claimed (the dollar amount the claim is for)
Past loss of earnings or earning capacity
Future loss of earnings or earning capacity
Medical expenses paid out-of-pocket
Pain and suffering
Any other loss arising out of the incident
D. Medical illness or injury records
Hospital and physicians’ medical and clinical records describing illness, injury, or death
Medical records release providing written authorization for MARAD to obtain historical
medical records
Name(s) and address(es) of hospital(s) and/or treating physician(s)
Certificates of Discharge for current and previous two years’ employment history as a
seafarer

Current and two previous calendar years of W-2, and income tax filing to show separate
historical employment earnings in occupational categories as both a seafarer and nonseafarer (if any)
Copies of medical not-fit-for-duty status reports and fit-for-duty declaration

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E. Information about reshipment status and non-seafarer employment (if any) subsequent to
medical medically-determined recovery from illness or injury
Location and date of registry for reshipment
Date of reshipment and identity of employer and vessel
If not reshipped, and employed in a non-seaman occupation, identity of employer, salary
and date employed