There is no charge for this evaluation

Injured Person Information:

Whom are you inquiring on behalf of? Minor Other Self

If you are NOT inquiring on your own behalf, what is your relationship?

Is the person deceased? Yes No

If deceased, the cause of death as stated on the death certificate:  

Was there an autopsy performed? Yes No   n/a 

Are you currently represented by counsel in an Asbestos Claim?
Yes No

Did you or the injured party ever work/live in California or New York?
Yes No

Please describe where you think exposure may have occurred:

Describe injuries or effects from asbestos exposure:

Other Information:

Yes No - I agree that by submitting this question, I will not be charged for the initial response. I understand that I am forming only a semi-confidential relationship.

Yes - I agree that the above does not constitute a request for legal advice and that I am not forming an attorney client relationship by submitting this question. I understand that I may only retain an attorney by entering into a fee agreement, and that I am not hereby entering into a fee agreement. I agree that the information that I will receive in response to the above question is general information and I will not be charged for the response to this e-mail question. I further understand that the law for each state may vary, and therefore, I will not rely upon this information as legal advice. Since this matter may require advice regarding my home state, I agree that local counsel may be contacted for referral of this matter.

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