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Camp Lejeune Questionnaire

Camp Lejeune Questionnaire

Your Contact Information

Do you have legal authorization to pursue claims on behalf of the individual that was at Camp Lejeune?(Required)

Injured Person Information

MM slash DD slash YYYY

Additional Information

Reason the injured individual was at Camp Lejeune?(Required)
Was the injured individual born at Camp Lejeune?(Required)
Was the injured individual at Camp Lejeune for at least 30 days?(Required)
Select all locations you lived at Camp Lejeune.(Required)
Please indicate time spent at Camp Lejeune (list each stay separately):
MM slash DD slash YYYY
MM slash DD slash YYYY

Medical Information

Presumptive Diseases
It 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.
Other Diagnoses / Illnesses
The 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.
Other Diagnoses / Illnesses (Continued)
Select additional fertility, pregnancy issues or infant injuries that occurred
Other Diagnoses / Illnesses (Part 3)
Select any additional diagnoses/diseases.

Emergency Contact Information

Are you working with another law firm?(Required)