Camp Lejeune Intake form

STEP 1: Speak with us to see if you Qualify

Camp Lejeune Intake form

*Are you a New or Existing Client? *

May I have your name? (Prefix)

*May I have your name? (First) *

May I have your name? (Middle)

*May I have your name? (Last) *

May I have your name? (Suffix)

*Date of birth *

*May I have the best phone number to reach you? *

*Do we have your permission to contact you in the event this call gets disconnected, or for other missing information regarding this matter? *

Alternate Phone

*Email *

*Address (Street Address) *

Address (Address Line 2)

*Address (City) *

*Address (State / Province) *

*Address (ZIP / Postal Code) *

Address (Country)

*Are you calling on behalf of yourself or someone else? *

What is their name? (Prefix)

What is their name? (First)

What is their name? (Middle)

What is their name? (Last)

What is their name? (Suffix)

What is their gender?

Other:

What is their Date of Birth?

What is their Social Security Number?

What is your relation to the person you are calling for?

What is your relation to the person you are calling for? If Other

Is the injured party a minor?

Are they deceased?

Date of Death

Can you provide us with a copy of your loved one's Death Certificate?

In what capacity do you represent your loved one?

Do you have legal authority to sign on their behalf?

If appointed as your loved one's representative, can you provide us with a copy of the Letters Testamentary?

*Are you/loved one currently represented by an attorney regarding Camp Lejeune Toxic Water? *

*Did you or a loved one live or work on the Camp Lejeune base for at least 30 days between August 1, 1953 and December 31, 1987? *

*What years did you/loved one live on the Camp Lejeune base? (FROM): *

*What years did you/loved one live on the Camp Lejeune base? (TO): *

*Did you/they work at the Hadnot Point Industrial Area at Camp Lejeune? *

*Where did you/your loved one live on base? *

Did you or a loved one spend any time at Camp Lejeune in Utero?

*In what capacity did you/loved one live or work at Camp Lejeune? *

*Why were you/your loved one at Camp Lejeune? *

Why were you/your loved one at Camp Lejeune? If Other reason, explain:

*What was the name of your/their employer? *

In which area of Camp Lejeune did you work for the private company?

What is the full name of the service member you/they were living with?

What is the full name of your/their mother?

*Were you/loved one diagnosed with any of the following? *

Infant Injuries in Utero:

Birth defects explained:

Other Cancer Details:

Other Serious Medical Condition Details:

*In what year were you first diagnosed with your/their injuries related to Camp Lejeune? If MORE THAN ONE, please list ALL injuries and approximate diagnosis years: *

*Did you/they drink alcohol? If so, how many drinks per day and for how long? *

*Did you/they smoke? If so, how many packs per day and for how long? *

Has anyone that lived in your household on the Camp Lejeune base passed away?

Please provide their Name and Cause of Death:

*Have you/loved one received any disability benefits related to Camp Lejeune Toxic Water? *

*Have you already sought compensation from the Navy for your/their injuries related to Camp Lejeune—either by filing a form with the Navy (not the VA), such as a form called an SF-95, or by filing a lawsuit against the United States? *

*You/Loved One Will Need To Communicate By Phone With An Attorney And Case Manager In Order To Gather More Facts For A Potential Claim. You Must Be Willing To Share, Confidentially, Your Medical Records And Personal Health Information With The Law Firm. After The Firm Receives The Signed Retainer And Claim Documents, You Will Be Contacted By A Case Manager Who Works With Your Attorney…They Will Need 15-20 Minutes Of Your Time For More Detailed Information. Are You Willing To Do This? *

Is there any additional information you would like to share with the attorneys regarding Camp Lejeune Toxic Water?

*How did you hear about our law firm? *

*Qualified / Disqualified *

Emergency Contact Name (Prefix)

*Emergency Contact Name (First) *

Emergency Contact Name (Middle)

*Emergency Contact Name (Last) *

Emergency Contact Name (Suffix)

*Emergency Contact Relationship to Plaintiff *

*Emergency Contact Phone Number

Emergency Contact Email

Emergency Contact Address (Street)