TJC Funnel

1
What has you or a loved one experienced?* This field is required.
Serious health issues?
Motor Vehicle Accident?
Sexual Abuse?
2
Serious Injury Cases: You May Qualify for These Cases(In Islamabad)* This field is required.Please Select the Case that Applies to You:
Exposed to Fire Fighting Foam?»
Exposed to Roundup? »
Exposed to Paraquat? »
Used Depo-Provera? »
Suffering from a Personal Injury?
»Used Hair Straightening products? »
Used Baby Formula?
»Used Talcum Powder? »
Defective Hernia Mesh? »
Used a Bard-Powerport? »
Used Ozempic? »
Exposed to PFAS? »
3
How long have you been exposed to AFFF?* This field is required.
Less than 1 year
1 or more years
4
On how many occasions were you directly exposed to firefighting foam (AFFF)?* This field is required.
1-9 Exposures
10 or more exposures
Never exposed
5
In what occupation were you directly exposed to firefighting foam (AFFF)?* This field is required.
Please Select
Please Select
Firefighter (civilian or military)
First Responder (civilian or military)
Airport personnel
Aviation engineer working around planes
Navy service member
Military service personnel who trained with AFFF
Other military personnel
Other occupation
6
Do you already have an attorney representing you on this case?* This field is required.
YESNO
7
Were you physically Injured in a motor vehicle accident?* This field is required.
YESNO
8
Did you receive medical treatment?* This field is required.
YESNO
9
Were you at fault?* This field is required.
YESNO
10
What date did the accident occur?* This field is required.
Date
Month
Day
Year
11
Do you have a police report of the incident?* This field is required.
YESNO
12
Do you already have an attorney representing you on this case?* This field is required.
YESNO
13
Briefly describe what happened* This field is required.
Huge
Large
Normal
Small
Ok
Ok
14
You May Qualify for These Cases: Please Select the Case that Applies to You:* This field is required.
Assaulted during a Uber/Lyft ride? »
Experience Abuse at a Mormon Church? »
15
Were you or someone you know assaulted by your driver during an Uber or Lyft ride between 2012-Present?* This field is required.
Yes, in a Lyft
Yes, in an Uber
No
16
What is the victim's gender?* This field is required.
Female
Male
17
Do you have any documentation related to your rideshare incident?* This field is required. Bank Statement Police Report Ride Share Service Incident Report Rideshare Service Receipt
YESNO
18
What type of abuse/assault did you suffer?* This field is required.
Please Select
Please Select
Physical abuse/assault
Verbal abuse/assault
Sexual abuse/assault
Inappropriate Touching
Indecent exposure
Kissing
Fondling
Oral Sex
Sexual Intercourse
Other abuse assault
No abuse/assault
19
What was the date of the incident?* This field is required.
Less than 1 year ago
1-5 years ago
More than 5 years ago
20
Do you already have an attorney representing you on this case?* This field is required.
YESNO
21
Find out if you are eligible for compensation* This field is required.
First Name
Last Name
22
Find out if you are eligible for compensation* This field is required.
Phone
Email
Should be Empty: