MESOTHELIOMA ATTORNEY

Law Firm of McDonald Worley, PC

Asbestos Exposure Information Form

We at the McDonald Worley Law Firm invite you to tell us about your needs and objectives. We can demonstrate how a relationship with our firm can get your the verdict you desire.

We appreciate you taking the time to provide us your information so we can evaluate your case and take up the fight for you and your loved one.

Please fill out the form below * Required Fields

Your Name:
*
City:
*
Zip:
*

Phone Number:
*
Work Number:

E-mail Address:
*

Street Address:
*
State:
*

Date of Birth:

Asbestos Information
Are you currently represented by an attorney in an Asbestos Claim?
Yes No

Has there been a diagnosis of
Asbestosis Yes No
Lung Cancer Yes No
Mesothelioma Yes No

Work History
Boilermaker Yes No

Operator Yes No

Brick mason Yes No

Pipe fitter Yes No

Welder Yes No

Steelworker Yes No

Insulator Yes No

Electrician Yes No

Millwright Yes No

Carpenter Yes No

Maintenance Mechanic Yes No

Sandblaster Yes No

Machinist Yes No

Grinder Yes No

Laborer Yes No

Other:

Union or Local:

Describe Asbestos Dust Exposure:

Work Exposure Locations & Dates:

Is this person deceased? Yes No
(typically you have two years from the date of death to file a claim, state laws may vary)

If YES, what is the name of the deceased:

Your relationship to the deceased:

Cause & Date of death: