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 Name

First Last

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Emergency Contact (Name & Phone Number)

Claimant Information

The Claimant is the person who was exposed to the toxic water.

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 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.

Enter the Approximate Timeframe That Claimant Was at Camp Lejeune

Claimant's Marital Status

Where Did Claimant Reside at Camp Lejeune?

Did Claimant Work at or Have Exposure to the 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

Location Where Claimant Died (City, State)

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.

Medical Information

Claimant's Medications

Please list the names of all known prescribed medications that Claimant took over the course of their lifetime, along with the approximate dates of use. (Ex: Zantac, 2018 - Present)

Claimant's Medical Providers

Please list the names of all known doctors and medical facilities that Claimant treated with over the course of their lifetime, along with the approximate dates of treatment. (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 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: 256 MB.

Name

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