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Camp Lejeune Water Contamination
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Roundup Lawsuit
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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
Injury occurred due to camp lejeune?
Please Select One
Case Description
Are you Injured at camp lejeune?
Yes
No
Have you appointed an attorney?
Yes
No
Is Currently incarcerated?
Yes
No
Pharmacy Name
Pharmacy Address
State
Pharmacy State
City
Zip
Phone
Fax
Doctor Name
Doctor Address
State
Doctor State
City
Zip
Phone
Fax
Hospital Name
Hospital Address
State
Hospital State
City
Zip
Phone
Fax
Were you or your loved one on active duty during your time at Camp Lejuene?
Yes
No
Did claimant ever file for bankruptcy?
Yes
No
Is claimant currently in bankruptcy?
Yes
No
Date of diagnosed
Relation to deceased?
Please Select One
First Name
Last Name
Email
Phone
Address
State
Emergency contact state
City
Zip
First Name
Last Name
Email
Phone
Injured Party's Date of Birth
Address
State
Injured party state
City
Zip
Injured Party's social
Is the injured party deceased?
Yes
No
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
Was claimant at CLJ for at least 30 days?
Yes
No
Does the claimant have a copy of their medical records?
Yes
No
Did the injured party, serve, live or work at Camp?
Please Select One
Injured Party Marital Status
Please Select One
Injured Party Relationship?
Please Select One
Which language the claimant speaks?
Did the claimant make a claim with the Navy?
Yes
No
What date was the claim placed with the Navy?
Was injured party's mother pregnant during stay at CLJ?
Yes
No
Which date did the pregnancy start?
Which date did the pregnancy end?
Was the injured party pregant during stay at CLJ?
Yes
No
What year did the injured party start at Camp LeJenue?
What year did the claimant left from Camp LeJenue?
Where was the injured party exposed at Camp LeJenue?
Please Select One
Who is the injured party?
Loved One
Self
Why stationed or posted at CLJ?
Please Select One
Agent Name
Select...
Injured Party Date of Death?
Other Injury?
Other Reason?
Other location?
The call recording for the lead as a URL
Current or former smoker?
Please Select One
How many smoke per day?
Who did the injured party live with at Camp LEJeune
Date of birth of person injured party lived with at Camp
Military Rank of person serving
How many years in service?
Occupation and Employer?
Name of School or daycare attended?
Does injured party collect disability benefits?
Yes
No
Is the cause of death of the injured party known?
Yes
No
What was the injured party's cause of death?
Which State did the injured party pass away in?
Injured party state
Address of person injured party stayed at CLJ
State of person who injured party stayed with at CLJ
State
City of person who injured party stayed at CLJ
Zip of person who injured party stayed with at CLJ
Age of person who injured party stayed with at CLJ?
Social security number?
What treatments did the injured party receive for their injury?
Date of death (If the person with the injured party was living with is deceased)
What is the relationship of the injured party and the person they lived with on base?
Please Select One
Number of person who injured party stayed with at CLJ?
Story of the client & their exposure?
Do you have any proof of your time at CLJ?
Yes
No
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