Case No. 02-02474 (Jointly Administered).United States Bankruptcy Court, N.D. Illinois, Eastern Division.
August 31, 2004
Andrew Goldman, Esq., Eric R. Markus, Esq., Wilmer Cutler Pickering Hale and Dorr LLP, New York, New York, Attorneys for Kmart Corporation.
Barbara L. Yong, Karen G. Kranbuehl, Field Golan LLP, Chicago, Illinois, Attorneys for Ernestine Gittens and Maria Valdivia.
AGREED ORDER BETWEEN KMART AND ERNESTINE GITTENS AND MARIA VALDIVIA
SUSAN SONDERBY, Chief Judge, Bankruptcy
This Agreed Order is entered into and submitted to the Court in accordance with the agreement of Kmart Corporation and certain of its subsidiaries, former debtors and debtors-in-possession in the above-captioned cases (collectively, “Kmart”) and Ernestine Gittens and Maria Valdivia (collectively, “Claimants”), in resolution of Claimants’ motion for reconsideration of the Order Disallowing Claims of Certain Personal Injury Claimants Not Complying With The Personal Injury Claims Resolution Procedures (Docket No. 25347) (“Motion”); it appearing to the Court that the relief should be granted,
IT IS HEREBY ORDERED, ADJUDGED AND DECREED THAT:
1. Claimants shall each complete a Questionnaire, the form of which is attached hereto as Exhibit A (the “Questionnaire”), providing all information requested, and serve such completed Questionnaire on Kmart, so as to be received on or before September 30, 2004 at the following addresses: (1) Kmart Corporation, 3100 West Big Beaver Road, Troy, Michigan 48084 (Attn: Silvana Romano) and (2) Wilmer Cutler Pickering Hale and Dorr, 2445 M Street, N.W., Washington, D.C. 20037 (Attn: Gwendolyn K. Ponder, Esq.).
2. This Court hereby vacates its Order Disallowing Claims of Certain Personal Injury Claimants Not Complying With The Personal Injury Claims Resolution Procedures ((Docket No. 15310) as to the claims filed by Ernestina Gittens (Claim No. 13370), and Maria Valdivia (Claim No. 14720) (the “Claims”). Kmart will be considered to have an objection as the amount of the Claims.
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3. Nothing in this Agreed Order shall be deemed an admission of fact on the part of Kmart with respect to the Claims or any facts alleged in the Motion, Kmart expressly reserves all rights to challenge the validity, priority and amount of the Claims, for reasons other than Claimants’ alleged failure to timely submit their Questionnaires by November 15, 2002, and to pursue any other claims, causes of action or potential offsets against the Claims.
4. This Court shall retain jurisdiction to hear any matters or disputes arising from or relating to this Agreed Order.
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Exhibit A Questionnaire
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QUESTIONNAIRE FOR PERSONAL INJURY CLAIMANTS
In re:Name and Address of Claimant: Kmart Corporation, et al. Case No. 02 B 02474 (SPS) ___________________________________ Chapter 11 Name ___________________________________ Address ___________________________________ City ___________________________________ State/Zip County ___________________________________ Phone Number
PART A — NOTICE Purpose of this Notice
According to court records, you previously filed a claim in the above-referenced cases. In order to estimate your claim for voting on a reorganization plan and provide information on your claim, you must complete this Questionnaire and mail it, postage prepaid, to Kmart Corporation, 3100 West Big Beaver Road, Troy, Michigan 48084.
Action Required by You
1. If you do not wish to pursue any claim you may have, disregard this notice and do not return it. You will not be allowed to vote on a reorganization plan if you do not return the Questionnaire on time.
2. If you wish to pursue any claim you may have against the Debtors arising from or relating to any medical services rendered to you or someone by or through whom you claim damages, you must:
(a) fully complete this Questionnaire, and
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(b) return the completed Questionnaire in the enclosed reply envelope. (Note: You must affix proper postage.) The reply must be delivered no later than November 15, 2002, or it will not be processed and you will not be allowed to vote on a proposed reorganization plan.
WARNING:IF YOU DO NOT RETURN THIS COMPLETED FORM BY NOVEMBER 15, 2002,YOUR CLAIM WILL BE ESTIMATED AT ZERO AND YOU WILL NOT BE ABLE TOVOTE ON A PROPOSED REORGANIZATION PLAN.
PART B — CLAIM INFORMATION
1. Give your date of birth: _________ 2. Date of injury: _____________
3. Where did the injury occur? _______________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ Please specify the location and address
4. Are you pursuing this claim against any other party? Yes No
If so, against whom (list the name, the addresses and counsel for each party, if known)? ____________________________________________________ ______________________________________________________________________ (Attach additional sheets if necessary)
5. Did you notify the Debtor in writing of the injury? (If yes, attach a copy of such writing.) Yes No
6. Is there a pending lawsuit regarding your claim? If so, identify the court where the lawsuit is pending, the case number and the judge, if known. ______________________________________________________________________ ______________________________________________________________________
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7. What type of injuries do you have? Provide a medical description of your injuries. (Please state if the claim is based, in whole or in part, on an injury to someone else.) _______________________________________________________________________ _______________________________________________________________________
8. How did the injury occur? _______________________________________________________________________ _______________________________________________________________________
9. Did you miss any work as a result of your injury? If so, how many days? _______________________________________________________________________ _______________________________________________________________________
10. Give the name and address of your employer and your salary at the time of your injury. _______________________________________________________________________ _______________________________________________________________________
11. Was anyone else injured at the time of your injury? (If yes, list the names and addresses.) _______________________________________________________________________ _______________________________________________________________________
12. List the names, addresses and phone numbers of all witnesses and people with relevant knowledge of your claim (including, but not limited to, any representatives or agents of the Debtors). _______________________________________________________________________ _______________________________________________________________________
13. Are treatments still being given for the injury? Yes No
(If yes, provide the name and address of the doctor that is currently treating you and the nature of the treatment.) _______________________________________________________________________ _______________________________________________________________________
14. Physician Data a. Give the name and address ___________________________ of any physician, clinic or ___________________________ hospitals that have treated this ___________________________ injury. Include treatment dates. ___________________________ (Attach additional sheets if necessary) ___________________________
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b. Itemize all damages you claim, including any damages for emotional distress, loss of consortium or pain and suffering. _______________________________________________________________________ _______________________________________________________________________
c. Give the total amount of the medical bills you incurred as a result of suffering your injury. _______________________________________________________________________ _______________________________________________________________________
d. Attach medical and hospital records which relate to your claim.
e. Itemize any other expenses you incurred as a result of the incident for which you are making a claim. _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________
f. Give a list of medical expenses and amounts paid by your insurance company as a result of your injury. _______________________________________________________________________ _______________________________________________________________________
g. Give the name, address and policy number of your insurance company. _______________________________________________________________________ _______________________________________________________________________
15. In what amount would you agree to settle your claim? (This is not the amount that you will receive on account of your claim. The amount you will receive depends upon the plan or plans of reorganization that may be approved.) ________________________________________________________________________ ________________________________________________________________________
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PART C — SIGNATURE NOTICE: UNDER FEDERAL LAW, CRIMINAL PENALTIES MAY BE IMPOSEDFOR FILING A CLAIM CONTAINING FALSE OR MISLEADING STATEMENTS.
I declare under penalty of perjury that the foregoingstatements are correct.
DATE: ____________________ __________________________ Claimant’s Signature
Please recheck each of your answers to be sure that you have completed this form fully and accurately.
NAME AND ADDRESS OF ATTORNEY OR OTHER AUTHORIZED AGENT
Complete this box if you have an attorney or other agent who represents you in this matter. If completed, all future notices will go to your attorney or agent rather than to you personally.
Name (First/Middle/Last)
Address
City/State/Zip
Country
Relationship to Claimant
Phone Number
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