North Toledo Chemical Release Questionnaire

Prepared by Attorneys John L. Huffman, John T. Murray, Leslie O. Murray, and Mark A. Skeldon

If you or anyone in your household was affected by the October 20, 2026 chemical release in North Toledo, please tell us what happened. Our attorneys have filed a proposed class action to hold those responsible accountable for the harm to residents and businesses in the surrounding community.

We encourage anyone who believes they were affected to respond, regardless of where they live or the extent of their injuries or losses. Whether you had temporary expenses and disruptions or significant injuries and financial harm, we want to hear from you. The case is in its early stages, and the court will ultimately decide who is included in any class.

This questionnaire is free, confidential (subject to applicable law and the needs of the litigation), and does not obligate you in any way. Submitting it does not by itself make you an individual client, determine whether you are part of the class, or prevent you from speaking with another attorney. We currently represent the named plaintiffs. If a class is certified, class members may be represented without signing an individual fee agreement, and the court will set the procedures governing their rights, including any right to opt out.

Questions marked with an asterisk (*) are required. A member of our team may follow up with you. Please do not delay seeking medical care or legal advice while waiting to hear from us.

First Name

Middle Name

Last Name

Date of Birth

Date

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Alternate Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email Address

example@example.com

Home Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Do you own or rent your home?

Other

What language do you prefer for follow-up?

Other

If other, which language?

Are you currently represented by an attorney about this incident?

Attorney or law firm name

Have you contacted any other law firms about this incident?

If yes, which law firms?

Have you spoken with anyone from the company involved, its insurance company, or a claims adjuster?

If yes, who did you speak with, when, and what was discussed?

Have you signed any document, or accepted any payment, gift card, or reimbursement, related to this incident?

If yes or not sure, describe what you signed or received and the date

Have you filed a claim through a company claims process or hotline?

Have you filed a homeowner's or renter's insurance claim?

Are you or anyone in your household employed by, or under contract with, the company or facility involved in the release?

If yes or not sure, provide the name and relationship to you

Were you a first responder or emergency worker at the scene?

If yes, what is your agency or employer?

Work or School Address (if different from home)

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Which zone were you in, according to the official orders?

Did you evacuate?

If you evacuated, where did you stay?

If you evacuated, what date did you return home?

Date

Where were you on the night of the release (October 20, 9:30 PM to 11:59 PM)?

Other

Where were you on October 21?

Other

Where were you on October 22?

Other

Where were you on October 23?

Other

If you answered Other for any date above, list the date and location

During the incident, did you notice any of the following?

Were your windows open, or were you outdoors, during the release?

About how many hours were you exposed before you left or sheltered in place?

Does your household have or use any of the following?

How many people live in your household, including you?

How many people in your household are under 18?

Household Member 1: Full Name, Date of Birth, Relationship to You, Whether home or in the affected area during the incident, Symptoms, and Parent or Legal Guardian name if under 18

Household Member 2: Full Name, Date of Birth, Relationship to You, Whether home or in the affected area during the incident, Symptoms, and Parent or Legal Guardian name if under 18

Household Member 3: Full Name, Date of Birth, Relationship to You, Whether home or in the affected area during the incident, Symptoms, and Parent or Legal Guardian name if under 18

Household Member 4: Full Name, Date of Birth, Relationship to You, Whether home or in the affected area during the incident, Symptoms, and Parent or Legal Guardian name if under 18

Household Member 5: Full Name, Date of Birth, Relationship to You, Whether home or in the affected area during the incident, Symptoms, and Parent or Legal Guardian name if under 18

Additional household members: name, date of birth, and relationship to you

Have you had any of the following symptoms since the incident?

If other, please describe

About when did your symptoms begin?

Date

Hour MinutesAM/PM Option

Are your symptoms still ongoing?

Did you visit a doctor, urgent care, or emergency room because of the incident?

If yes, list each visit: provider or facility name, date, and type of visit

If asked, would you be willing to sign an authorization so we can obtain your medical records?

Did you have out-of-pocket costs because of the incident?

Lodging ($)

Food ($)

Travel and fuel ($)

Pet boarding ($)

Other costs: describe and give the amount

Did you keep receipts for these costs?

Did you miss work because of the incident?

If yes, who is your employer?

If yes, about how many days or hours of work did you miss?

Do you own a business that was affected by the incident?

If yes, provide the business name and describe how it was affected

Was any of your property affected?

Other

Please describe how your property was affected

Cleaning or remediation costs ($)

Do you have any of the following related to the incident?

Upload photos, videos, or documents

How would you prefer that we contact you?

What is the best time to reach you?

How did you hear about us?

If other, please specify

I agree to receive text messages about my inquiry from the attorneys listed above and their staff

Acknowledgment
By submitting this questionnaire, I understand that my information is confidential and will be shared only with the attorneys handling this matter, and that submitting it does not create an attorney-client relationship.

I have read and understand the acknowledgment statement above

North Toledo Chemical Release Questionnaire

Respondent Contact and Representation

Release Location, Evacuation, and Exposure

Household Members

Symptoms and Medical Treatment

Expenses, Work, Business, and Property Impacts

Evidence Uploads and Follow-Up Preferences

Text Message Consent and Acknowledgment