America Solution-BOB AFFF

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Case Review Form

First Name

Last Name

Phone

Address

State

Eg.California

City

Zip Code

Location

Representative First Name

Representative Last Name

Representative Phone

Representative Relation to Injured Party

Please Select one

Current Age of Claimant

Please Select one

If the claimant is deceased, do they fall within the statute of limitations for their state?

YesNo

How many years between first exposure and diagnosis?

How many times were you exposed to AFFF?

Please Select one

What was your occupation?

Please Select one

Is the injury validated with the required latency and exposure as per the criteria?

YesNo

Is an attorney representing you on this matter?

YesNo

What injury have you been diagnosed with?

Please Select one

Were you exposed to AFFF after 1960?

YesNo

If you were not a firefighter, were you a current or past military member that was exposed on a base or ship?

YesNo

How many years were you exposed to AFFF?

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