Industrial disease enquiry form

Please complete this form with as much detail as possible

Full name (Required)

Email address

Contact telephone number (Required)

Address (Required)

Are you making this enquiry on behalf of:

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?

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 read our privacy statement to understand how your personal information may be stored and used by Leigh Day & Co solicitors.

Please press the send button once you have completed the form