Benzene Submission
To have a lawyer review your concern fill out the information and write a brief description of your Benzene related injury in the form below. This information will be kept private and confidential and used for the sole purpose of evaluating your case. Please note that without a phone number or e-mail address we will not be able to contact you. Attorneys serve all 50 states. Please read and agree to our terms and conditions.
Title:
First Name:
M. I.
Last Name:
Address:
City:
State:
Zip Code:
Phone Number (day):
Phone Number (eve):
Email Address
What is the Injured's relationship to you?:
Injured's Date of Birth? (ie mm/dd/19yy)
Where you or they exposed to Benzene?:
Where were you or they exposed?:
Date(s) of Exposure?
Do you or they have Leukemia?:
If yes, what type of Leukemia?
If you have had another type of cancer or disease, please specify
Date of Diagnosis?:
If injured is no longer living, what was the date of death?
What date was the connection between your illness and Benzene exposure made?
What professions/industries have you worked in that may have exposed you to Benzene?
