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Industrial disease enquiry form

Please complete this form with as much detail as possible

Title (Required)

First name

Surname (Required)

email address

Contact telephone number (Required)

Mobile phone number

Address (Required)

Are you making the enquiry on behalf of (Required)

Yourself

Family/relative

Friend

What disease are you enquiring about? (Required)

In which year were you/the victim diagnosed?

Does the person making the claim have any dependents? (Required)

Do you have a solicitor currently representing your case?

Yes

If yes please provide the name of the solicitor's firm

Please outline the main points of your case, including any exposure to harmful substances (eg asbestos) that may have caused the industrial disease (Required)

Please press the send button once you have completed the form