*Name:

*Address:

*City:

*State:
Choose One AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

*Zip:

*E-mail address:

*Home Phone:

Best Time to Call
AM PM

Business Phone:

Best Time to Call
AM PM

Who was injured?
Choose One Me Family Member Other

If "Other," please describe:

Injured person's name (if different from above):

Address:

City:

State:
Choose One AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

Zip:

E-mail address:

Home Phone:

Business Phone:

Is the person deceased?
Yes  No 

If deceased, cause of death as stated on the death certificate:

Date of death:

Personal Injury Information

Date of birth:

When did the injury occur?

Does this case involve a minor (under 18 years old)
Yes  No 

Is the Injured person currently represented by counsel in a Silicosis Claim?
Yes  No 

Has the injured person been diagnosed with any of the following?
Accelerated Silicosis
Acute Silicosis
Chronic Silicosis
Conglomerate Silicosis
Pneumoconioses

If yes to any of the above, when was the diagnosis made?

Do you believe that the injured party was exposed to Silica at work?
Yes  No 

Did work exposure cause any other medical problems?
Yes  No 

If "yes", please describe.

Describe the injured person's health before exposure to Silica and current health status:

Current Symptoms
Shortness of breath
Chronic or severe cough
Chest pain
Fatigue
Fever
Lack of appetite
Cyanosis or bluish skin
Tuberculosis
Other pulmonary problems

Did the victim lose wages as a result of the injury?
Yes  No 

The injured party has not been diagnosed, but believes that he/she was injured from silica exposure.
Yes  No 

Please select the type of activities where the injured person would have most likely been exposed to Silica.
Chipping, hammering & drilling of rock/concrete
Demolition of brick, concrete, or masonry
Dry sweeping concrete, sand, or rock dust
Glass manufacturing
Grinding, and/or chipping on masonry or concrete
Loading, hauling, and dumping of rock and concrete
Mining, both surface and underground
TRailroad work, maintenance or construction
Sawing, hammering or drilling masonry or concrete
Sandblasting of buildings or oilfield equipment
Tile and grout work
Trenching and excavation
Working in the shipbuilding industry
Other job/occupation

How long was the victim exposed to Silica?
From:

To:

Please list all states where exposure to Silica occurred

Please list any additional information here: