AFFF Claim Application Form

Myself On behalf of a family member

First Name

Last Name

Phone Number

Email

Address

City

State

Zip

Diagnosing/treating doctor:

Hospital or medical facility name

Phone

Address

City

State

Zip

Military/Work exposure:

Are you a current or former member of the U.S. Military?

Yes No

Are you a current or former firefighter or closely associated personnel?

Yes No

Did you use AFFF during your time in the military?

Yes No

Did you use AFFF during your career?

Yes No

Message

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Main Office:

2160 Highland Ave,
Birmingham, AL 35205

Get Directions

205.328.9200

Washington DC Office:

2101 L St NW, Suite 800,
Washington, DC 20037

Get Directions

202.903.0727

Business Hours:

Monday – Friday
8:00 AM – 5:00 PM

Saturday & Sunday
Closed

No representation is made that the quality of the legal services to be performed is greater than the quality of legal services performed by other lawyers. This web site is designed for general information only. The information presented at this site should not be construed to be formal legal advice nor the formation of a lawyer/client relationship.