environmental litigation group, p.c.
Processing Toxic Claims since 1990
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AFFF Claim Application
Myself
On behalf of a family member
First Name
Last Name
First Name
Last Name
Phone Number
Email
Address
City
State
Zip
Disease:
Bladder Cancer
Colon cancer
Kidney Cancer
Liver Cancer
Lymphoma
Non-Hodgkin's Lymphoma
Pancreatic Cancer
Prostate Cancer
Renal Cancer
Testicular Cancer
Thyroid Cancer
Other cancer:
Infertility
Kidney disease/problems
Non-Cancerous Tumor
Thyroid disease/problems
Other non-cancer condition:
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
Branch of Service
Dates served:
Type of work in the military:
List all ships/bases you were on/stationed:
Are you a current or former firefighter or closely associated personnel?
Yes
No
Employer
City
State
Zip
Started
Ended
Job Title
Did you use AFFF during your time in the military?
Yes
No
Location of use
Frequency of use
Time period
Provide detailed information regarding use
Did you use AFFF during your career?
Yes
No
Location of use
Frequency of use
Time period
Provide detailed information regarding use
Message
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