CL DV TD iFrame
Qualifiers
At Camp Lejeune?
Yes
No
Have you already signed up with an attorney to represent you on this?
Yes
No
Were you or your loved one there for more than 30 days?
Yes
No
Your name
Your name
First
First
Last
Last
Will you be filing on behalf of yourself or a Loved One?
Myself
Loved One
(Injured Party) Did you/they live or work at Camp Lejeune?
Lived
Worked
Did you/they live on-base or off-base?
on-base
off-base
FAIL FAIL FAIL
OBO
Name
Name
First
First
Last
Last
Gender
Male
Female
Date of Birth
Are they living or deceased?
Living
Deceased
Date of Death
Your relationship to this person?
self
parent
sibling
spouse
child
grandparent
grandchild
in_law
step_parent
Do you have authority to sign for them?
Yes
No
Do you have proof or authority?
Yes
No
Do you have any documents that proves their claim?
Yes
No
Diagnosis
What injury were you/they diagnosed with?
Aplastic anemia
Myelodysplastic Syndromes
Acute Myeloid Leukemia
ALS
Appendix cancer
Autoimmune diseases
Bile Duct Cancer
Bladder Cancer
Brain cancer
Breast Cancer
Cancers
Cardiac birth defects
Central Nervous System Cancer
Cervical Cancer
Colon Cancer
Colorectal cancer
End stage renal disease
Esophageal Cancer
Female Breast Cancer
Female Infertility [while exposed to CL water]
Fertility, Pregnancy, and Infant Injuries
Gallbladder cancer
Glioblastoma - Spinal cancer
Heart Disease
Hodgkins Disease
Hodgkins Lymphoma
Intestinal Cancer
Kidney Cancer
Kidney damage
Kidney Disease
Kidney Failure
Leukemia
Leukemia (child and adult)
Liver Cancer
Lung Cancer
Lymphoma
Male Breast Cancer
MDS
Miscarriage [while exposed to CL water]
Multiple Myeloma
Non-Hodgkin’s lymphoma
Non-Hodgkins Lymphoma
Ovarian Cancer
Pancreatic Cancer
Parkinsons disease
Parkinson's Disease
Prostate Cancer
Rectal Cancer
Renal Toxicity
Scleroderm
Scleroderma
Sinus cancer
Soft Tissue Cancer
Spinal cancer - Glioblastoma
Thyroid Cancer
What year were you/they diagnosed?
What was the Doctor's name who gave the diagnosis?
Don't remember
Name
Name
Hospital/Facility where the diagnosis was done
Address of that Hospital/Facility
Phone Number of the Hospital/Facility
Did you/they smoke?
Yes
No
For how long (years)?
How many packs per day?
Treated at the same facility as you/they were diagnosed?
Yes
No
Name of the Doctor/Physician who treated you/them?
Name of the Doctor/Physician who treated you/them?
First
First
Last
Last
Hospital/Facility where the treatment was done
Address of the treatment Hospital/Facility
Phone Number of the treatment Hospital/Facility
Self
Do you have a Primary Care Physician (PCP)?
Yes
No
Name of the PCP
Name of the PCP
First
First
Last
Last
Name of the PCP Hospital/Facility
Address of the PCP
Phone Number of the PCP
Add'l Case Info
First Exposure Date
Last Exposure Date
What was your/their role during exposure at Camp Lejeune?
*
Military
Dependent
Worker
Did you/they work at the Hadnot Point Industrial Area at Marine Corps Base Camp Lejeune?
Yes
No
Have a copy of medical records in your possession that you can provide to our case management and legal team?
Yes
No
Emergency Contact Name
Emergency Contact Name
First
First
Last
Last
Emergency Contact Phone Number
Emergency Contact Relation to Client
Military
What unit were you/they assigned to while aboard the base?
Did you/they have a Post-Military Civilian Employment at Camp Lejeune?
Yes
No
Were you/they a Civilian Employee Working for a Private Company on Base or a Civil Service Employee?
Private company on base
Civil Service Employee
Name of employer or company
Address of employer or company worked for?
What was your/their capacity (title) while at Camp Lejeune?
What were your/their job responsibilities?
Dependent
Full name of your sponsor
Full name of your sponsor
First
First
Last
Last
Their date of birth
or last 4 of SSN
What unit were they assigned to while aboard the base?
Is your Sponsor alive or deceased?
Alive
Deceased
Address of your Sponsor
Phone number of your Sponsor
Worker
Name of employer or company you/they worked for?
Address of your employer or company you/they worked for?
TextWhat was your/their capacity (title) while at Camp Lejeune?
What were your/their job responsibilities?
Housing/Residence
Did you/they live in
a family housing area
barracks
both
Locations lived in while at Camp Lejeune?
Please explain in as much detail as possible, the place/area you lived ON BASE and your recollection of your time at Camp Lejeune.
Did you/they work on base?
Yes
No
Where did you/they work on base? Name specific location(s) of Camp Lejeune.
What did you do for work on base?
Where did you live off base?
Visited any locations ON BASE? (name some)
Did you do any of these for at least 30 total days ON BASE?
Validity Checks
Can you provide details of at least 2 corroborators?
Yes
No
Corroborator 1 Name and Phone Number
Corroborator 2 Name and Phone Number
Provide photos or some kind of proof to the attorneys that you were in fact on base during the time claimed?
Yes
No
Do you remember places you went to on base, or can you share what you did while at Camp Lejeune so we can use that to figure out locations?
Yes
No
Please explain how you believe you were exposed to the water at Camp Lejeune other than by drinking water.
Do you have your DD214 or personnel records in your possession that show you lived at Camp Lejeune?
Yes
No
Do you recall your Military Service Number?
Yes
No
Do you recall your MOS (Military Occupation Service Code)?
Yes
No
Do you receive VA Disability Benefits?
Yes
No
All Braches - Did you seek compensation from the Navy for your/their injuries related to Camp Lejeune? (SF-95 Form)
Yes
No
Signing Set-up
Last 4 SSN
Driver’s License or Gov ID #
Address for Notary and Retainer
Email for E-Sign
Best Time to Contact
Gender
Male
Female
Date of Birth
Marital Status
Option 1
Occupation
Appointment Date
Time
12
1
2
3
4
5
6
7
8
9
10
11
:
00
30
AM
PM
call_uuid
If you are human, leave this field blank.
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