Lung cancer claim application

Completing the form on behalf of:

Myself On behalf of a family member

If you or a loved one has been diagnosed with lung cancer please specify if you were exposed to one or more of the following:

Tobacco smoke

Asbestos

Coke oven emissions

AFFF

Toxic chemicals

Approximate Date of Diagnosis

Current/former occupation

Did you serve in the military

Yes No

Is this the first time you are filing a case?

Yes No

First Name

Last Name

Phone Number

Email

Address

City

State

Zip

Message

I declare under penalty of perjury that all information provided on this form is true and correct to the best of my knowledge.

Social Media:

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.