CLN - Paraquat - 3 Step Form - Step 1 Page

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Fields

Time is limited. Find out if you may qualify.

Were you or a loved one exposed to Paraquat?*

Yes No

Did the exposure occur after 1961?*

Yes No

Is this claim for you or a loved one?*

Self Loved One

What is your loved one's name?*

First Name*

Last Name*

What is your Relationship?*

I'm their spouse I'm their child I'm their parent Other

Are they still with us?*

Yes No

Was the Paraquat you were exposed to used on a crop?*

Yes No

Was the Paraquat they were exposed to used on a crop?*

Yes No

Was the Paraquat used on government-owned land?*

Yes No

Was the Paraquat used on government-owned land?**

Yes No

Were you diagnosed with Parkinson’s Disease after being exposed to Paraquat?*

Yes No

Was your loved one diagnosed with Parkinson’s Disease after being exposed to Paraquat?*

Yes No

Have you developed shaking or tremors?*

Yes No

Have they developed shaking or tremors?*

Yes No

Do you currently live in one of the following states:*

Tennessee Kentucky Louisiana Puerto Rico No

Do they currently live in one of the following states:*

Tennessee Kentucky Louisiana Puerto Rico No

Do they currently live in one of the following states?*

Tennessee Kentucky Louisiana Puerto Rico No

Did they live in one of the following states at the time of death:*

Tennessee Kentucky Louisiana Puerto Rico No

Did they live in one of the following states at the time of death?*

Tennessee Kentucky Louisiana Puerto Rico No

When were you diagnosed with Parkinson's or start experiencing symptoms?*

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Month

Day

Year

When were they diagnosed with Parkinson's or start experiencing symptoms?*

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Month

Day

Year

What was their date of death?*

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Month

Day

Year

Have you been exposed to Agent Orange?*

Yes No

Have they been exposed to Agent Orange? *

Yes No

Are you currently working with another attorney on this matter?*

Yes No

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All contact information you provide is confidential.

Name*

First Name*

Last Name*

Cell Phone*

Address*

Address Line 1

City

State

ZIP Code

Loved One's Phone*

Loved One's Address:

City

State

ZIP Code

Date of Death:

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Month

Day

Year

What is the cause of death as listed on their Death certificate?

Date

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Month

Day

Year

Time

Hour

Minute

: :

Second

Client Code

Venture*

DX/DOD Date:*

Tort

URL

uuid

Submission Result

Submission Type

Delivery Type

Progress