Camp Lejeune Email Agency Campaign | AMMS

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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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