Case
What is your Full Name
*
First Name
Middle Name
Last Name
Email
*
Confirmation Email
example@example.com
What is your cell phone number? (or main number if no cell phone)
*
Please enter a valid phone number.
Current Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Did the Claimant Firefighter receive a cancer diagnosis after exposure to aqueous film-forming foam (AFFF), more commonly known as firefighting foam?
*
YES
NO
Please verify that you are human
*
Submit
Should be Empty: