America Solution-AFFF

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Case Review Form

First Name

Last Name

Email

Phone

Dob

Address

State

State

City

Zip

Lead Id

Lead Social Number

Sub ID

Sub ID2

User Agent

Cell phone provider

Please Select One

Cell provider other

Relation to injured party

Please Select One

Has claimant ever been convicted of a felony?

Yes

No

Has the injured party been diagnosed with one of the following injuries?

Case Description

Already signed with an attorney?

Yes

No

Associated Doctor Name

Associated Doctor Address

Associated Doctor State

Associated Doctor State

Associated Doctor City

Associated Doctor Zip

Associated Doctor Phone

Associated Doctor Fax

Doctor Name

Doctor Address

Doctor State

Doctor State

Doctor City

Doctor Zip

Doctor Phone

Doctor Fax

Employer Name

Exposure Home Address

Exposure Home State

Exposure Home State

Exposure Home City

Exposure Home Zip

What was the felony and what year ?

Does the injured party have proof of being a firefighter?

Yes

No

Gender

Male

Female

How does claimant know that AFFF was used (narrative) ?

Did claimant ever file for bankruptcy?

Yes

No

Is claimant currently in bankruptcy?

Yes

No

Where and when was the bankruptcy filed?

Doctor Associated Injury with AFFF

Yes

No

Date of diagnosed

Date of Exposure to Doctor Associate

Date of Doctor Visit to Report Symptoms

Details of SSD Claim

Workers Compensation Details

Injured Party's First Name

Injured Party's Alternate first name

Injured Party's Last Name

Injured Party's Alternate last name

Injured Party's Middle Name

Injured Party's Alternate middle

Injured Party's Email

Injured Party's Phone

Injured Party's Date of Birth

Injured Party's Address

Injured Party's Address 2

Injured Party's State

Injured party state

Injured Party's City

Injured Party's Zip

Injured Party's social

Is the injured party deceased?

Yes

No

Did the injured party pass away within the past 2 years?

Yes

No

Did the injured party pass away from testicular or kidney cancer in the past 4 years?

Yes

No

Was the potential claimant’s injury first diagnosed by a medical professional within the past 20 years (2003 to present)?

Yes

No

Did the injured party represented by a proper fiduciary?

Yes

No

Lead stage 2

Please Select One

Injured Party Marital Status

Please Select One

Were medical records found in the CMDS

Yes

No

N/A

Military status

Please Select One

Other type of exposure

Primary Care Physician Full Name

Primary Care Physician Address

Primary Care Physician State

Primary care physician state

Primary Care Physician City

Primary Care Physician Zip Code

Primary Care Physician Phone

Primary Care Physician Fax

Primary insurance name

Primary insurance address

Primary insurance phone

Does claimant have proof of AFFF use?

Yes

No

Has the injured party filed a social security disability claim for AFFF exposure

Yes

No

Symptoms start date

Place of AFFF exposure (NAME, Address, CITY, STATE)

Work hours

Has the injured party filed a workers comp claim for AFFF exposure

Yes

No

Date exposure started

Date exposure ended?

Describe the nature of AFFF exposure

Who is the injured party?

Loved One

Self

Injured Party Exposed to AFFF

Please Select One

Agent Name

Select...

Injured Party Date of Death?

The call recording for the lead as a URL

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