GKN Aerospace Toxic Chemical Emergency Crisis Client Intake Sheet

GKN Aerospace Toxic Chemical Emergency Crisis Client Intake Sheet

THE LAW OFFICES OF JAMES J. CHO
Full Name

First NameLast Name
Date of Birth (D.O.B.)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Driver’s License Number (DL#)
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Children under 18 [Name(s), D.O.B.]
How were you affected by the GKN Aerospace toxic chemical emergency crisis? Please elaborate, as applicable, e.g., evacuated from when to when; costs and expenses incurred as a result of the evacuation; lost wages; experienced physical, especially respiratory, difficulties; business closure from when to when, and the resulting lost business income, etc.
If you received medical treatment, please provide medical insurance information (Insurance company name; adjuster’s/agency’s name; phone number; fax number; business address; email address; policy number; claim number, if a claim has already been made).
Medical providers (Name, Address, Telephone No., Treating Physician).
How much did you pay for treatment and to which provider?
Any additional information that you would like to add.
Preferred language, if other than English (Chinese, Spanish, or Vietnamese only)
Should be Empty: