46 C.F.R. § 327.4

(a) Form. The claim must be in writing, in any form, and must provide the following:

(1) Designated as a claim;

(2) Disclose that the object sought is the administrative allowance of the claim;

(3) Comply with the requirements of this part; and

(4) Filed as provided in § 327.5.

(5) The claim must be signed or attested to by the claimant. The statements made in the claim should be made to the best of the knowledge of the claimant and are subject to the provision of 18 U.S.C. 287 and 1001 and all other penalty provisions for making false, fictitious, or fraudulent claims, statements or entries, or falsifying, concealing, or covering up a material fact in any matter within the jurisdiction of any department or agency of the United States.

(b) Contents. Each claim must include the following information:

(1) With respect to the seaman:

(i) Name;

(ii) Mailing address;

(iii) Email address;

(iv) Date of birth;

(v) Legal residence address;

(vi) Place of birth; and

(vii) Merchant mariner license or document number and last four digits of the seamen's social security number.

(2) With respect to the basis for the claim:

(i) Name of vessel on which the seaman was serving when the incident occurred that is the basis for the claim;

(ii) Place where the incident occurred;

(iii) Time of incident—year, month and day, and the precise time of day, to the minute, where possible;

(iv) Narrative of the facts and circumstances surrounding the incident, including a statement explaining why the United States is liable for this claim;

(v) Pictures, video recordings and other physical evidence related to the case and

(vi) The names, addresses, and telephone numbers, if available, of others who can supply factual information about the incident and its consequences.

(3) A sum certain dollar amount of claim, which includes a total for all amounts sought. The claim must explain the amounts sought for:

(i) Past loss of earnings or earning capacity;

(ii) Future loss of earnings or earning capacity;

(iii) Medical expenses paid out of pocket;

(iv) Pain and suffering; and

(v) Any other loss arising out of the incident (describe).

(4) All medical and clinical records of the licensed healthcare practitioner and hospitals related to a seaman's claim for injury, illness, or death must be attached. If the claimant does not have a copy of each record, the claimant must identify every licensed healthcare practitioner and hospital having records relating to the seaman and provide written authorization for MARAD to obtain all such records. The claim must also include the number of days the seaman worked as a merchant mariner and the earnings received for the current calendar year, as well as for the two preceding calendar years.

(5) If the claim does not involve a seaman's death, the following information must be submitted with the claim:

(i) Date the seaman signed a reemployment register as a merchant mariner;

(ii) Copy of the medical fit-for-duty certificate issued to the seaman;

(iii) Date and details of next employment as a seaman; and

(iv) Date and details of next employment as other than a seaman.

(6) If the claim is for other than personal injury, illness or death, the claim must provide all supporting information concerning the nature and dollar amount of the loss.