Camp Lejeune Form Your Contact InformationName(Required) First Last Email(Required) PhoneAddress(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code What is your relation to the individual that was at Camp Lejeune?(Required) Do you have legal authorization to pursue claims on behalf of the individual that was at Camp Lejeune?(Required) Yes No No, but I would be willing to gain legal authorization Injured Person InformationName(Required) First Last Gender(Required) Marital Status(Required) Birthday(Required) MM slash DD slash YYYY Additional InformationReason the injured individual was at Camp Lejeune?(Required) Military Military dependent Civilian employee Other reason Was the injured individual born at Camp Lejeune?(Required) Yes No Was the injured individual at Camp Lejeune for at least 30 days?(Required) Yes No Select all locations you lived at Camp Lejeune.(Required) Barracks Berkeley Manor Camp Geiger Courthouse Bay Hadnot Point Holcomb Boulevard Hospital Point Knox Trailer Park Mainside Barracks Midway Park Montford Point/Camp Johnson New River Onslow Beach Paradise Point Rifle Range Tarawa Terrace Watkins Village Other Please indicate time spent at Camp Lejeune (list each stay separately):From MM slash DD slash YYYY To MM slash DD slash YYYY Medical InformationPresumptive DiseasesIt is presumed that Individuals diagnosed with one of the following diseases qualify to seek justice for their service-connected disease if they were stationed/living/working at Camp Lejeune for at least 30 days between 1953 and 1987. Proof of diagnosis is required. Select any presumptive diseases. Aplastic anemia Bladder cancer Breast cancer Esophageal cancer Female infertility Hepatic steatosis (fatty liver disease) Kidney cancer Leukemia Liver cancer Lung cancer Miscarriage Multiple myeloma Myelodysplastic syndromes Neurobehavioral effects Non-Hodgkin's lymphoma Parkinson’s disease Renal toxicity Scleroderma Other Diagnoses / IllnessesThe following diagnoses/illnesses are not currently considered “presumptively service-connected” by the VA. However, you still qualify for compensation if you meet the Camp Lejeune date qualifications. Select any additional cancers. Appendix cancer Brain cancer Bile duct cancer Colorectal cancer Gallbladder cancer Intestinal cancer Pancreatic cancer Prostate cancer Sinus cancer Soft tissue sarcoma Spinal cancer Thyroid cancer Other cancer Other Diagnoses / Illnesses (Continued)Select additional fertility, pregnancy issues or infant injuries that occurred Birth defect Cognitive disability Congenital malformation (microcephaly) Conjoined twins Other fertility/pregnancy issue or infant injury Other Diagnoses / Illnesses (Part 3)Select any additional diagnoses/diseases. Autoimmune diseases Other diagnosis, disease or injury Please list any cysts, tumors, or polyps below.Emergency Contact InformationName(Required) Email(Required) Phone(Required)Are you working with another law firm?(Required) Yes No CAPTCHA Δ
