Please complete the following questionnaire regarding your Camp Lejeune Toxic Water case.

Camp Lejeune Toxic Water Questionnaire

Instructions

Please answer all questions fully to the best of your ability. Some questions may not apply to your specific case. In that situation, simply put ‘N/A’ as your entry. If you do not know the answer to a particular question, you should state ‘Unknown’ as your entry.

Personal Information

Your Full Legal Name
Address
DO NOT file bankruptcy during pending litigation without first consulting your Attorney as it may impact your ability to recover settlement proceeds.

Claimant Information

The Claimant is the person who was exposed to the toxic water.
Full Legal Name of Claimant (If Different)
Claimant's Date of Birth
Where Did Claimant Reside at Camp Lejeune?

Decedent Information (If Applicable)

If Claimant is not deceased, you may skip this section.
Claimant's Date of Death

Injury Information

Claimant's Injuries
Please select the injuries that you believe may be related to Claimant’s exposure to the toxic water at Camp Lejeune (check all that apply).
(Ex: Kidney Disease March 1990, Parkinson’s Disease December 2005)

Medical Information

Please list the names of all known doctors and medical facilities that treated Claimant for their injuries/conditions related to the toxic water exposure. (Ex: Dr. John Doe, Montgomery Clinic, Chemotherapy 2015-2017)

Miscellaneous

Please provide any other facts or information that you believe may be relevant to this case.
This field is for validation purposes and should be left unchanged.