Mesothelioma Free Case Review Form
 
Contact Information

Fill out the following form or call 1-800-518-5103 24 hours a day, 7 days a week for a Free Case Review.
First Name
Last Name
Home Number
Work Number
Cell Phone
Email Address
Re-type your Email Address
Street Address
City
State/Zip
Injured Person's Contact Information

The injured person is
First Name
Last Name
Home Number
Work Number
Cell Phone
Email Address
Street Address
City
State/Zip
Date of Birth
Sex Male Female
Has the person been diagnosed with:
If other, please describe diagnosis:
Name of Treating Doctor or Physician:
When was the person diagnosed?
What state was the person living in when diagnosed?
Was the person exposed to asbestos?
Where was the person exposed to asbestos?
What type of work did the person do?
Is the person still living?
Yes No
If deceased, what is the cause of death stated on the death certificate?
If the person has deceased, when did the person pass away?
Did the person smoke?
Yes No  
Do you or the diagnosed person currently have an attorney for an asbestos or mesothelioma claim?
Yes No
Please use this space to tell us any additional information you would like to provide

a. I agree that submitting this form and the information contained within does not establish an attorney client relationship.
b. I agree that my information will be reviewed by more than one attorney and/or law firm.
c. I agree that the information that I will receive in response to the above question is general information and I will not be charged for the response to this e-mail question. I further understand that the law for each state may vary, and therefore, I will not rely upon this information as legal advice. Since this matter may require advice regarding my home state, I agree that local counsel may be contacted for referral of this matter.

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