Free Mesothelioma Case Review

Please fill out the form below and click submit. We will review and contact you.

Name

Phone Number

Address

Are you calling on your own behalf or someone else?

Myself

Someone Else

Is this a mesothelioma, asbestos cancer claim or something else?

Mesothelioma

Asbestos Cancer Claim

Something Else

Is this a living or death case?

Living

Death

If this is a living case, when did a doctor tell you about the disease?

If a doctor diagnosed a disease do you have a medical record and what is the doctor's name and location?

Where did the injured or deceased work and what was the job title?

Do you have a work history starting from the first to last job?

Do you recall the names and locations of co workers living or dead?

If the injured or deceased was married list any wives and children and dates of marriage

Has the injured or deceased ever filed a workers compensation claim or lawsuit before regarding lung issues and if so, when and where?

Is the injured or deceased currently represented by a lawyer and if so who?

Is the injured able to come to the office?

Does the injured or deceased have any other medical conditions such as heart, kidney or diabetes?

What is the smoking history of the injured or deceased?

If the injured or deceased is the spouse or child of a worker exposed to asbestos what is the work history of the worker?

Is there anything else you want to tell us such as how you learned about us?

Thanks for submitting!