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Contact nos.	206.957.9510 / 888.647.6007
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Personal Information

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Case Facts
1 - Has a doctor said that you, a family member, or some other person you know has an asbestos disease, or that an asbestos disease was a contributing factor in his or her death?
- Yes
- No
2 - If yes, please indicate which asbestos disease(s) the doctor diagnosed
- Mesothelioma
- Asbestosis
- Lung Cancer
- Throat Cancer
- Other
3 - Would the case you are describing be a personal injury case or a wrongful death case?
- Personal Injury
- Wrongful Death
4 - Is this case for you or someone else, and if it is for someone else, what is his or her relationship to you?
- Me
- Someone Else
His or her relationship to you?
5 - What was the date of birth for the person with the asbestos disease?
6 - What was the date of diagnosis?
7 - If this is a wrongful death case, what was the date of death?
8 - Have you or someone else filed a lawsuit and/or a workers’ compensation claim concerning this case?
Additional Information
Please enter any additional information about this asbestos claim, as well as any comments or questions you may have, in the following space
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