LNG - Camp Lejeune - 3 Step Form

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Were you or a loved one exposed to the water supply at Camp Lejeune?*

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

Did the exposure occur between August 1, 1953 and December 31, 1987?*

Yes No

Did you suffer from any of the following cancers after exposure?*

Acute Myeloid Leukemia (AML) Bladder cancer Brain cancer Breast cancer Central Nervous System cancer (CNS) Cervical cancer Esophageal cancer Non-Hodgkin's Lymphoma Kidney cancer Leukemia Liver cancer Lung cancer Multiple myeloma Myelodysplastic Syndrome Non-Hodgkins Lymphoma Ovarian cancer Prostate cancer Rectal cancer None of the Above

Did they suffer from any of the following cancers after exposure?*

Did you suffer from any of the following serious conditions after exposure?*

Cardiac defect Epilepsy Fatty liver disease (hepatic steatosis) Female infertility Immune disorders Kidney damage Miscarriage Myelodysplastic syndromes Nerve damage Neurobehavioral effects Parkinson’s disease Renal toxicity/toxicity/disease Scleroderma None of the Above

Did they suffer from any of the following serious conditions after exposure?*

Date of Diagnosis:*

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Year

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

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Name*

First Name*

Last Name*

Cell Phone*

Address*

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ZIP Code

Date of Birth

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Loved One's Date of Birth

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Loved One's Date of Death

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Date

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