Roundup and Paraquat Case Evaluation Prerequisite Questionnaire
Please complete the following questionnaire to help us assess your case. You may also call 319-294-8777 to speak with someone in our office.
Have you (or a loved one) used the product Roundup or Paraquat?
*
Yes
No
Which products have been used (or which have you been exposed to)?
Roundup (Glyphosate)
Paraquat
Where was Roundup or Paraquat used?
*
Please Select
-- Please select one --
Home
Work
Both
How many years was Roundup or Paraquat used?
*
Please Select
-- Please select one --
Less than 1 year
1 - 3 years
4 - 10 years
11+ years
No Use
Have you (or a loved one) been diagnosed with any of the following conditions?
*
Non-Hodgkins Lymphoma
B-Cell Lymphoma
Chronic Lymphocytic Leukemia (CLL)
Follicular Lymphoma
T-Cell Lymphoma
Hairy Cell Leukemia (HCL)
Marginal Zone Lymphomas
Mantle Cell Lymphoma (MCL)
Diffuse Large B-Cell Lymphoma (DLBCL)
Lymphoblastic Lymphoma (Waldenstrom Macroglobulinemia)
Burkitt Lymphoma
Mesothelioma
Other Lymphoma Cancer
No Cancer
Parkinson's Disease
Other
Are you or a loved one currently represented by an attorney in regard to your Roundup or Paraquat related injury/illness?
*
Yes
No
Please note: completion of this evaluation does not guarantee compensation.
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Do I qualify?
Based on your answers, you may be eligible for compensation.
A representative from our office will review your responses and contact you within 2 business days.
Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Please share any additional information you think will assist our staff in evaluating your case.
Submit
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