Camp Lejeune Webform New -

CAMP LEJEUNE CALL CENTER WEBFORM

"*" indicates required fields

Call Center Code*

Agent Name*

Was Claimant or a loved one lived or worked at Camp Lejeune between 1953 and 1987 and developed a serious illness*

Name*

First Last

Phone*

Email*

Claimant Address*

Street Address Address Line 2 City State ZIP Code

Date of Birth*

Date Diagnosed*

Case Description*

Active Duty in Military?*

Bankruptcy Filed*

Injured - Name*

First Last

Injured - Party*

Relationship with Claimant

Diagnosis Injury*

Martial Status*

Are You Active Duty*

Claimant Exposed in which Building on Base*

Do you have copy of medical records*

Worked with another law firm*

Are you Currently Incarcerated*

Why Were you or your loved one at Camp Lejeune*

Jornaya Lead ID*

By clicking "Submit My Claim", I confirm I have read and agreed to this websites terms of service and privacy policy and provide my express written consent via electronic signature authorizing AxLawSuit Team, and one or more law firms, their agents and marketing partners to contact me about my case and other related legal products and services to the number and email address I provided (including any wireless number.