Military Bases Liable Companies & VA Claim Application

Myself On behalf of a family member

First Name

Last Name

Phone Number

Address

City

State

Zip

Date of birth

Date of death (if completed for a decedent)

Have you been diagnosed with one of the following?

Approximately when were you diagnosed?

Are/were you in the U.S. Military?

Are/were you stationed on one of the following bases?

How long did you live on base?

* If stationed at Camp Lejeune between August 1953 and December 1987, did you spend there a minimum of 30 consecutive days?

Yes No

Message

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Military Bases Claim Application Form