New Client 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

First Last

Phone

Address

Street Address Address Line 2 City State ZIP / Postal Code

Within What County Is Your Current Residence Located?

Emergency Contact (Name & Phone Number)

Have you ever declared bankruptcy? If so, has the bankruptcy been resolved?

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)

First Last

Your Relationship to Claimant (Ex: Self, Wife, Father, etc.)

Claimant's Date of Birth

Claimant's Social Security Number

Claimant's Status at Time of Exposure

Claimant's Branch of Service

If Claimant is a Civilian Military Dependant, please Enter the Full Name of the Claimant's Sponsor.

If Claimant Was a Civilian Employee Working for a Private Company on Base, Please Enter the Name of the Company Here.

Claimant or Military Sponsor's TOTAL Years of Military Service

Approximate Month/Year Claimant was FIRST Exposed to the Water at Camp Lejeune

Approximate Month/Year Claimant was LAST Exposed to the Water at Camp Lejeune

Estimated TOTAL Months of Exposure to the Water at Camp Lejeune

Claimant's Marital Status

Where Did Claimant Reside at Camp Lejeune?

Was Claimant Exposed to Hadnot Point Industrial Area in Camp Lejeune?

Decedent Information (If Applicable)

If Claimant is not deceased, you may skip this section.

Claimant's Date of Death

Claimant's Residence at Time of Death (City, State)

Did Claimant have a History of Tobacco Use?

Did Claimant have a History of Alcohol Use?

Is There Any Known Family History of Similar Condition/Cancer/Injury That Caused Claimant's Death?

Did Claimant Have a Last Will?

Does Claimant Have an Estate?

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).

If You selected "Other" in the Field Above, Please Provide a Description Here.

Provide Approximate Date (Month/Year) of Diagnosis for EACH Injury/Condition(s) Selected

(Ex: Kidney Disease March 1990, Parkinson’s Disease December 2005)

Medical Information

Claimant's Medical Providers

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

Other Information

Please provide any other facts or information that you believe may be relevant to this case.

Upload Relevant Documents

If you have copies of Claimant’s Military Records such as DD214s, Medical Records, Death Certificate (If Applicable), Last Will (If Applicable), or other relevant documents, please upload them here. If you are unable to upload, please email the files to admin@foster-law.com or mail physical copies to our Mobile, AL office located at 1 St. Louis St., Suite 1002, Mobile, AL 36602.

Drop files here or

Max. file size: 20 MB.

Phone

This field is for validation purposes and should be left unchanged.