veteransupport.us Open in urlscan Pro
67.225.146.145  Public Scan

Form analysis
1 forms found in the DOM

POST /contact.php

<form action="/contact.php" method="post" id="myForm" onsubmit="return validate(this)">
  <table>
    <tbody>
      <tr>
        <td><label for="firstName">First Name<br>
            <input id="firstName" name="firstName" type="text" size="21">
          </label></td>
        <td><label for="lastName">Last Name<br>
            <input id="lastName" name="lastName" type="text" size="21">
          </label></td>
      </tr>
      <tr>
        <td><label for="address">Mailing Address<br>
            <input id="address" name="address" type="text" size="21">
          </label></td>
        <td><label for="city">City<br>
            <input id="city" name="city" type="text" size="21">
          </label></td>
      </tr>
      <tr>
        <td><label for="state">State<br>
            <select id="state" name="state" size="1">
              <option value="None Selected" selected="selected">Please Select:</option>
              <option value="AK">AK</option>
              <option value="AL">AL</option>
              <option value="AR">AR</option>
              <option value="AZ">AZ</option>
              <option value="CA">CA</option>
              <option value="CO">CO</option>
              <option value="CT">CT</option>
              <option value="DC">DC</option>
              <option value="DE">DE</option>
              <option value="FL">FL</option>
              <option value="GA">GA</option>
              <option value="HI">HI</option>
              <option value="IA">IA</option>
              <option value="ID">ID</option>
              <option value="IL">IL</option>
              <option value="IN">IN</option>
              <option value="KS">KS</option>
              <option value="KY">KY</option>
              <option value="LA">LA</option>
              <option value="MA">MA</option>
              <option value="MD">MD</option>
              <option value="ME">ME</option>
              <option value="MI">MI</option>
              <option value="MN">MN</option>
              <option value="MO">MO</option>
              <option value="MS">MS</option>
              <option value="MT">MT</option>
              <option value="NC">NC</option>
              <option value="ND">ND</option>
              <option value="NE">NE</option>
              <option value="NH">NH</option>
              <option value="NJ">NJ</option>
              <option value="NM">NM</option>
              <option value="NV">NV</option>
              <option value="NY">NY</option>
              <option value="OH">OH</option>
              <option value="OK">OK</option>
              <option value="OR">OR</option>
              <option value="PA">PA</option>
              <option value="RI">RI</option>
              <option value="SC">SC</option>
              <option value="SD">SD</option>
              <option value="TN">TN</option>
              <option value="TX">TX</option>
              <option value="UT">UT</option>
              <option value="VA">VA</option>
              <option value="VT">VT</option>
              <option value="WA">WA</option>
              <option value="WI">WI</option>
              <option value="WV">WV</option>
              <option value="WY">WY</option>
            </select>
          </label></td>
        <td><label for="zip">Zip-code<br>
            <input id="zip" name="zip" type="text" size="5" maxlength="5">
          </label></td>
      </tr>
      <tr>
        <td><label for="phone">Telephone<br>
            <input id="phone" name="phone" type="text" size="21">
          </label></td>
        <td><label for="email">E-Mail Address<br>
            <input id="email" name="email" type="text" size="21">
          </label></td>
      </tr>
      <tr>
        <td colspan="2"><label>
            <input name="diagnosed" type="checkbox" id="diagnosed" value="with mesothelioma" checked=""> Diagnosed with Mesothelioma</label><br><br></td>
      </tr>
      <tr>
        <td colspan="2"><label><strong>In addition, please send me the following:</strong></label></td>
      </tr>
      <tr>
        <td colspan="2"><input type="checkbox" name="packet1" value="Federal Benefits for Dependents and Survivors 2010">
          <label for="packet1">Federal Benefits for Dependents &amp; Survivors</label>
        </td>
      </tr>
      <tr>
        <td colspan="2"><input type="checkbox" name="packet2" value="Understanding 
          and Enrolling in the VHA">
          <label for="packet2">Understanding and Enrolling in the VHA</label>
        </td>
      </tr>
      <tr>
        <td colspan="2"><input type="checkbox" name="packet3" value="Disability Claim Forms">
          <label for="packet3">Disability Claim Forms</label>
        </td>
      </tr>
      <tr>
        <td colspan="2"><label for="comment">Comments / Questions<br>
            <textarea id="comment" name="comment" cols="" rows=""></textarea>
          </label></td>
      </tr>
      <tr>
        <td colspan="2"><input id="submit" type="submit" name="submit" value="SUBMIT">
          <a href="/privacy/pop.php" target="_blank" title="View our
          privacy policy"><img src="/img/privacy.gif" alt="Privacy Policy" class="privacy"></a>
        </td>
      </tr>
      <tr>
        <td>&nbsp;</td>
      </tr>
    </tbody>
  </table>
  <input type="hidden" readonly="" name="visitor_ip" value="104.237.193.29" size="100">
  <input type="hidden" readonly="" name="referrer_url" id="referrer_url" size="100">
  <input type="hidden" readonly="" name="landing_page_url" id="landing_page_url" size="100">
  <input type="hidden" readonly="" name="dateoflead" id="dateoflead" value="2022-08-08" size="100">
  <input type="hidden" readonly="" name="incoming" id="incoming" value="INCOMING" size="100">
  <input type="hidden" readonly="" name="lead_source" id="lead_source" value="veteransupport.us" size="100">
</form>

Text Content

For Immediate Assistance Call
1-800-899-6195
 * Home
 * Asbestos Exposure
 * Mesothelioma, Lung Cancer & Asbestosis
 * Veterans Health Administration
 * Filing A Claim


RECEIVE FREE INFORMATION FOR VETERANS WITH MESOTHELIOMA:

 * Bereavement Counseling
 * Health Care
 * Home Loans
 * Life Insurance

 * National Cemetery Scheduling Office
 * Pension Management Center
 * Special Health Issues
 * VA Benefits

First Name
Last Name
Mailing Address
City
State
Please Select: AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME
MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI
WV WY Zip-code
Telephone
E-Mail Address
Diagnosed with Mesothelioma

In addition, please send me the following: Federal Benefits for Dependents &
Survivors Understanding and Enrolling in the VHA Disability Claim Forms Comments
/ Questions
 


VETERANS & MESOTHELIOMA

This web site is dedicated to helping those recently diagnosed with
mesothelioma, as well as the surviving spouses and dependents of military
personnel who died from mesothelioma due to asbestos exposure during their
military service.

We are grateful for the opportunity to provide quality information and
assistance to family members suffering the loss of their husbands, wives, sons,
daughters, mothers, and fathers. This includes information on the benefits they
are entitled to from the Veteran's Affairs Department. To find out more about
what you qualify for in VA benefits and other financial assistance, contact us
now.


LEARN ABOUT MESOTHELIOMA, LUNG CANCER & ASBESTOSIS

Click For More


INFORMATION ON THE VETERANS
HEALTH ADMINISTRATION

Click For More


GET HELP FILING A CLAIM & THE NECESSARY PAPERWORK

Click For More

 * Home
 * Asbestos Exposure
 * Mesothelioma, Lung Cancer & Asbestosis
 * Veterans Health Administration
 * Filing A Claim