Asbestosis, pleural plaques and mesothelioma questionnaire

If you would like a free initial assessment of your potential asbestosis claim by e-mail or telephone, kindly complete this short questionnaire.

Please note that the boxes marked with an asterisk * must be filled in fully, so as to allow the completed online form to be submitted to us.

Thank you.

Which asbestos-related condition has been diagnosed?
Mesothelioma
Asbestosis
Pleural plaques
Diffuse plural thickening
Lung cancer
Other

When was the above diagnosis provided?
Select -> 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Other Select -> January March April May June July August September October November December Select -> 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Are you the infected person, or a relative?
Infected person
Wife
Widow
Son
Daughter
Other

In which occupation did the exposure to asbestos occur?
Select -> Lagger Joiner Car mechanic Maintenance worker Boiler attendant Painter Shipyard worker Plumber Roofer Locomotive Engineer Power station worker Fire protection worker Other

Do you know the identity of the employer (or employers) who caused the exposure to asbestos?
Yes
No
Not sure

Did the exposure take place at premises owned by the employer, or at premises owned by somebody else?
Employer's Premises
Other person’s premises
Not sure

Did the exposure to asbestos take place with one employer, or more than one?
One employer
Two employers
Three employers
Four employers
Five employers
More than five employers

Is the employer (or the main employer) who caused the exposure still in existence?
Yes
No
Not sure

Is the employer (or the main employer) who caused the exposure insured?
Yes
No
Not sure

When did the main exposure to asbestos take place? (Multiple selections allowed)
Select -> Early 1950s Mid 1950s Late 1950s Early 1960s Mid 1960s Late 1960s Early 1970s Mid 1970s Late 1970s Early 1980s Mid 1980s Late 1980s Other

How frequent was the exposure to asbestos?
Select -> Hourly Daily Weekly Monthly Yearly Infrequent Other

Did the employer provide any warnings about the dangers of asbestos?
Yes
No
Not sure

Did the employer provide any protective equipment?
Yes
No
Not sure

Are there any witnesses who might be able to confirm the exposure?
Yes
No
Not sure

Have any of the above witnesses also suffered asbestos related symptoms?
Yes
No
Not sure

Have any of the above witnesses also made compensation claims?
Yes
No
Not sure

Where do you live in the UK?
Select -> South East South West London Wales East Anglia West Midlands East Midlands North East North West Scotland Other

Would you prefer a telephone call at home or at work?
At home
At work

Which day of the week would you prefer to be contacted?
Select -> Any day Sunday Monday Tuesday Wednesday Thursday Friday Saturday

When is the most convenient time to speak?
Select -> Early morning Late morning Lunchtime Early afternoon Late afternoon Early evening

Please give a convenient telephone number where we can reach you*:

Please state your name*

Please give a convenient e-mail address where we can reach you

Please state any further relevant facts that we might need to know about:

Kindly state how you heard about us, or which search engine you used:
Select -> Law Society Other solicitors Citizens Advice Bureau Personal Recommendation Yellow Pages Infoseek Northern Light Lycos Open Directory Ask Jeeves Fast Search Lycos Alta Vista Yahoo! MSN Hotbot AOL Excite Anzwers Google Other search engine Other referral source

Please click the submit button to send us the details, which will be treated in the strictest confidence, and not released to any third parties.

We will then contact you as close as possible to the time you specified. Any advice given regarding your potential claim will be on a free, no obligations basis, and does not constitute the acceptance of formal legal instructions.

Thank you for completing this questionnaire. Your interest is much appreciated and we look forward to hearing from you.