lawsuit-winning.com
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Submitted URL: https://s3.amazonaws.com/erurkysqxoguifibniczftiyeerrtmtb/d.html#qs=r-adbaibjhffjffafhdfdiiacdffdhddafhgfdabafhgfdabajfac...
Effective URL: https://lawsuit-winning.com/camp-lejeune1/es/?campaign_id=413&crid=299331721&afid=217&cid=36711&sid1=3569&sid2=102f2a23f5c7f...
Submission: On January 18 via manual from US — Scanned from US
Effective URL: https://lawsuit-winning.com/camp-lejeune1/es/?campaign_id=413&crid=299331721&afid=217&cid=36711&sid1=3569&sid2=102f2a23f5c7f...
Submission: On January 18 via manual from US — Scanned from US
Form analysis 1 forms found in the DOM
Name: main_form — POST /camp-lejeune1/es/submit.php
<form id="main_form" name="main_form" method="post" class="form-horizontal" action="/camp-lejeune1/es/submit.php">
<div class="container" style="background: white">
<div class="row">
<div id="myProgress" style="width:100%">
<div id="myProgressBar">0%</div>
</div>
<div class="col-md-12" id="welcome_title" style="padding: 10px;">
<p>
<strong>Hi there. I can help you see if you qualify for a Camp Lejeune claim! </strong>
<br> The information you provide me is confidential and will only be shared with the lawyers I work with.
</p>
</div>
</div>
<div class="row" style="padding: 10px;">
<div class="col-md-12" style="text-align: left">
<fieldset class="pb-3 pb-md-0 text-center" id="div_relationship">
<div class="form-check" id="relationship_form_check">
<span><strong>Is the affected individual you or a loved one?</strong></span><br>
<input type="radio" class="btn-check" name="relationship" id="relationship_myself" autocomplete="off" value="myself">
<label class="btn btn-primary myselfLabel" for="relationship_myself" style="width:100%;border:solid grey 1px;">Myself</label><br>
<input type="radio" class="btn-check" name="relationship" id="relationship_loved_one" autocomplete="off" value="loved_one">
<label class="btn btn-primary lovedOneLabel" for="relationship_loved_one" style="width:100%;border:solid grey 1px;">Loved One</label>
</div>
</fieldset>
<fieldset class="pb-3 pb-md-0 text-center" id="div_served">
<div class="form-check">
<span>
<strong>Did you or a loved one Serve, Live or Work at Marine Corps Base Camp Lejeune between Aug. 1953 and Dec. 1987?</strong>
</span>
<br>
<input type="radio" class="btn-check" id="served_yes" name="served" autocomplete="off" value="1">
<label class="btn btn-primary" for="served_yes" style="width:100%;border:solid grey 1px;">Yes</label><br>
<input type="radio" class="btn-check" id="served_no" name="served" autocomplete="off" value="0">
<label class="btn btn-primary" for="served_no" style="width:100%;border:solid grey 1px;">No</label>
</div>
</fieldset>
<fieldset class="pb-3 pb-md-0 text-center" id="div_diagnosis">
<div class="row">
<div class="col-md-12" style="background-color:#FFDB58;border-radius:4px;">
<span>
<i class="fa fa-lightbulb"></i>
<strong>**Diagnosis is needed to determine if you have a valid case against Camp Lejeune</strong>
</span>
</div>
<div class="col-md-12">
<span>
<strong>Have you or a loved one been diagnosed with:</strong>
</span>
<br>
<select name="diagnosis" id="diagnosis" class="form-control-lg" style="width:75% !important;margin-left:auto;margin-right:auto">
<option value="" selected="selected" style="">[ Select ] </option>
<option value="acute_lymphoblastic_leukemia"> Acute Lymphoblastic Leukemia (ALL) </option>
<option value="acute_myeloid_leukemia"> Acute Myeloid Leukemia (AML) </option>
<option value="amyotrophic_lateral_sclerosis"> Amyotrophic Lateral Sclerosis (ALS) </option>
<option value="anal_cancer"> Anal Cancer </option>
<option value="appendix_cancer"> Appendix cancer </option>
<option value="aplastic_anemia"> Aplastic Anemia </option>
<option value="atrial_septal_defect"> Atrial Septal Defect </option>
<option value="bile_duct_cancer"> Bile duct cancer </option>
<option value="birth_defects_malformation"> Birth defects/malformation </option>
<option value="bladder_cancer"> Bladder Cancer </option>
<option value="bone_cancer"> Bone Cancer </option>
<option value="brain_cns"> Brain CNS Cancers </option>
<option value="breast_cancer"> Breast Cancer </option>
<option value="cardiac_birth_defects"> Born with Cardiac Birth Defects </option>
<option value="cervical_cancer"> Cervical Cancer </option>
<option value="central_nervous_system_cancer"> Central nervous system cancer </option>
<option value="childhood_cancer"> Childhood Cancers </option>
<option value="chronic_lymphocytic_leukemia_cll"> Chronic Lymphocytic Leukemia (CLL) </option>
<option value="chronic_myelogenous_leukemia_cml"> Chronic Myelogenous Leukemia (CML) </option>
<option value="colorectal_cancer"> Colorectal cancer </option>
<option value="dental_issues"> Dental Issues/Tooth </option>
<option value="early_onset_dementia"> Early-onset dementia </option>
<option value="esophageal_cancer"> Esophageal Cancer </option>
<option value="extragonadal_germ_cell_cancer"> Extragonadal Germ Cell cancer </option>
<option value="eye_cancer"> Eye Cancer </option>
<option value="fallopian_tube_cancer"> Fallopian Tube Cancer </option>
<option value="female_infertility"> Female Infertility </option>
<option value="fetal_death"> Fetal Death </option>
<option value="gallbladder_cancer"> Gallbladder cancer </option>
<option value="gastrointestinal_cancer"> Gastrointestinal Cancer </option>
<option value="germ_cell_cancer"> Germ Cell Cancer </option>
<option value="gestational_trophoblastic_disease"> Gestational Trophoblastic disease </option>
<option value="hairy_cell_leukemia"> Hairy Cell Leukemia </option>
<option value="head_and_neck_cancer"> Head and Neck cancer </option>
<option value="heart_attack"> Heart Attack </option>
<option value="hepatic_steatosis"> Hepatic Steatosis </option>
<option value="hodgkins_lymphoma"> Hodgkins Lymphoma </option>
<option value="infertility"> Infertility </option>
<option value="intestinal_cancer"> Intestinal cancer </option>
<option value="kidney_cancer"> Kidney Cancer </option>
<option value="kidney_disease"> Kidney Disease </option>
<option value="laryngeal_cancer"> Laryngeal Cancer </option>
<option value="leukemia"> Leukemia </option>
<option value="liver_cancer"> Liver Cancer </option>
<option value="lung_cancer"> Lung Cancer </option>
<option value="metastatic_cancer"> Metastatic cancer </option>
<option value="miscarriage"> Miscarriage </option>
<option value="multiple_myeloma"> Multiple Myeloma </option>
<option value="multiple_sclerosis"> Multiple Sclerosis (MS) </option>
<option value="mycosis_fungoides"> Mycosis Fungoides </option>
<option value="myelodysplastic_syndromes"> Myelodysplastic Syndromes (MDS) </option>
<option value="neurobehavioral_effects"> Neurobehavioral Effects </option>
<option value="nhl"> Non-Hodgkin's Lymphoma (NHL) </option>
<option value="ovarian_cancer"> Ovarian cancer </option>
<option value="pancreatic_cancer"> Pancreatic Cancer </option>
<option value="parkinsons_disease"> Parkinson's Disease </option>
<option value="patent_ductus_arteriosus"> Patent Ductus Arteriosus </option>
<option value="primary_cns_lymphoma"> Primary CNS Lymphoma </option>
<option value="prostate_cancer"> Prostate Cancer </option>
<option value="rectal_cancer"> Rectal Cancer </option>
<option value="renal_toxicity"> Renal Toxicity </option>
<option value="scleroderma"> Scleroderma </option>
<option value="sinus_cancer"> Sinus cancer </option>
<option value="soft_tissue_sarcoma"> Soft tissue sarcoma </option>
<option value="spinal_cancer"> Spinal cancer </option>
<option value="stomach_cancer"> Stomach Cancer </option>
<option value="testicular_cancer"> Testicular Cancer </option>
<option value="tetralogy_of_fallot"> Tetralogy of Fallot </option>
<option value="thyroid_cancer"> Thyroid Cancer </option>
<option value="transposition_of_great_arteries"> Transposition of the Great Arteries </option>
<option value="uterine_cancer"> Uterine Cancer </option>
<option value="vascular_tumors"> Vascular Tumors </option>
<option value="ventricular_septal_defect"> Ventricular Septal Defect </option>
<option value="other"> Other </option>
<option value="no_diagnosis"> None </option>
</select>
</div>
</div>
</fieldset>
<fieldset class="pb-3 pb-md-0 text-center" id="div_mother_pregnant">
<div class="form-check">
<span><strong>Did your mother reside at CLJ when you were born, or was your mother pregnant with you when she resided at Camp Lejeune?</strong></span><br>
<input type="radio" class="btn-check" id="mother_pregnant_yes" name="mother_pregnant" autocomplete="off" value="1">
<label class="btn btn-primary" for="mother_pregnant_yes" style="width:100%;border:solid grey 1px;">Yes</label><br>
<input type="radio" class="btn-check" id="mother_pregnant_no" name="mother_pregnant" autocomplete="off" value="0">
<label class="btn btn-primary" for="mother_pregnant_no" style="width:100%;border:solid grey 1px;">No</label>
</div>
</fieldset>
<fieldset class="pb-3 pb-md-0 text-center" id="div_have_attorney">
<div class="form-check">
<span><strong>Do you currently have another law firm representing you on this claim?</strong></span><br>
<input type="radio" class="btn-check" id="have_attorney_yes" name="have_attorney" autocomplete="off" value="1">
<label class="btn btn-primary" for="have_attorney_yes" style="width:100%;border:solid grey 1px;">Yes</label><br>
<input type="radio" class="btn-check" id="have_attorney_no" name="have_attorney" autocomplete="off" value="0">
<label class="btn btn-primary" for="have_attorney_no" style="width:100%;border:solid grey 1px;">No</label>
</div>
</fieldset>
<fieldset class="pb-1 pb-md-0 text-center" id="gender">
<div class="row">
<div class="col-md-12">
<div class="form-check">
<span>
<strong>Please select the gender of the injured individual:</strong>
</span>
<br>
<input type="radio" class="btn-check gender" name="gender" id="gender_female" autocomplete="off" value="female">
<label class="btn btn-primary" for="gender_female" style="width:100%;border:solid grey 1px;"> Female </label>
<br>
<input type="radio" class="btn-check gender" name="gender" id="gender_male" autocomplete="off" value="male">
<label class="btn btn-primary" for="gender_male" style="width:100%;border:solid grey 1px;"> Male </label>
</div>
</div>
</div>
</fieldset>
<fieldset class="pb-1 pb-md-0 text-center" id="contact_info">
<span><strong>Your Claim Results Are Ready !</strong></span><br><br>
<span>Receive your claim results by submitting your information so we can connect you with a lawyer.</span>
<div class="row input-group mb-0">
<div class=" col-md-12">
<input vtype="not_empty" type="text" class="form-control form-control-lg " id="edit_firstname" name="edit_firstname" placeholder="First Name" value="" minlength="3">
</div>
<div class=" col-md-12">
<input vtype="not_empty" type="text" class="form-control form-control-lg" id="edit_lastname" name="edit_lastname" placeholder="Last Name" value="" minlength="3">
</div>
</div>
<div class="row input-group mb-0 ">
<div class=" col-md-12">
<input type="email" id="edit_email" name="edit_email" placeholder="Email" pattern="^([\w\.\-]+)@([\w\-]+)((\.(\w){2,3})+)$" data-required="true" class=" form-control form-control-lg " value="">
</div>
<div class=" col-md-12">
<input class="form-control form-control-lg" data-val="true" pattern="^[\(]?[2-9]{1}[0-9]{2}[\)]?[.\- ]?[2-9]{1}[0-9]{2}[.\- ]?[0-9]{4}$" data-val-regex="Please enter a valid number" data-val-required="Phone is required." id="edit_phone"
name="edit_phone" placeholder="Phone" type="tel" value="" data-required="true">
</div>
</div>
<div class="row input-group mb-0">
<div class=" col-md-12">
<input vtype="zip" type="text" class="form-control form-control-lg" id="edit_zip" name="edit_zip" placeholder="Zip" maxlength="5" minlength="5" value="">
</div>
</div>
</fieldset>
<fieldset class="pb-1 pb-md-0" id="div_may_have_claim">
<div class="card mb-3 text-center">
<div class="card-header bg-success text-white">You May Have A Claim!</div>
<div class="card-body">
<p class="card-text">Based on the information you provided it appears you may have a claim. <br>We just have a few more questions before we connect you with one of our lawyers. </p>
</div>
</div>
<div class="row deceased_row text-center">
<fieldset class="pb-3 pb-md-0" id="div_deceased">
<div class="form-check">
<span><strong>Is the injured party deceased?</strong></span><br>
<input type="radio" class="btn-check" id="deceased_yes" name="deceased" autocomplete="off" value="1">
<label class="btn btn-primary" for="deceased_yes" style="width:100%;border:solid grey 1px;">Yes</label><br>
<input type="radio" class="btn-check" id="deceased_no" name="deceased" autocomplete="off" value="0">
<label class="btn btn-primary" for="deceased_no" style="width:100%;border:solid grey 1px;">No</label>
<input type="radio" class="btn-check" id="deceased_na" name="deceased" autocomplete="off" value="N/A" hidden="">
</div>
</fieldset>
</div>
</fieldset>
</div>
<fieldset class="pb-1 pb-md-0 text-center" id="div_deceased_date">
<div class="row">
<div class="col-md-12">
<span><strong>When did your loved one pass away?</strong></span><br>
<div class="row">
<div class="col-md-4">
<select id="edit_deceased_month" name="edit_deceased_month" class="form-select form-dob-select" vtype="not_empty" style="width: 100% !important;">
<option value="" selected="selected">Month</option>
<option value="01"> Jan</option>
<option value="02"> Feb</option>
<option value="03"> Mar</option>
<option value="04"> Apr</option>
<option value="05"> May</option>
<option value="06"> Jun</option>
<option value="07"> Jul</option>
<option value="08"> Aug</option>
<option value="09"> Sep</option>
<option value="10"> Oct</option>
<option value="11"> Nov</option>
<option value="12"> Dec</option>
</select>
</div>
<div class="col-md-4">
<select id="edit_deceased_day" name="edit_deceased_day" class="form-select form-dob-select" vtype="not_empty" style="width: 100% !important;">
<option value="" selected="selected">Day</option>
<option value="01"> 1</option>
<option value="02"> 2</option>
<option value="03"> 3</option>
<option value="04"> 4</option>
<option value="05"> 5</option>
<option value="06"> 6</option>
<option value="07"> 7</option>
<option value="08"> 8</option>
<option value="09"> 9</option>
<option value="10"> 10</option>
<option value="11"> 11</option>
<option value="12"> 12</option>
<option value="13"> 13</option>
<option value="14"> 14</option>
<option value="15"> 15</option>
<option value="16"> 16</option>
<option value="17"> 17</option>
<option value="18"> 18</option>
<option value="19"> 19</option>
<option value="20"> 20</option>
<option value="21"> 21</option>
<option value="22"> 22</option>
<option value="23"> 23</option>
<option value="24"> 24</option>
<option value="25"> 25</option>
<option value="26"> 26</option>
<option value="27"> 27</option>
<option value="28"> 28</option>
<option value="29"> 29</option>
<option value="30"> 30</option>
<option value="31"> 31</option>
</select>
</div>
<div class="col-md-4">
<select id="edit_deceased_year" name="edit_deceased_year" class="form-select form-dob-select" vtype="not_empty" style="width: 100% !important;">
<option value="">Year</option>
<option value="2023"> 2023</option>
<option value="2022"> 2022</option>
<option value="2021"> 2021</option>
<option value="2020"> 2020</option>
<option value="2019"> 2019</option>
<option value="2018"> 2018</option>
<option value="2017"> 2017</option>
<option value="2016"> 2016</option>
<option value="2015"> 2015</option>
<option value="2014"> 2014</option>
<option value="2013"> 2013</option>
<option value="2012"> 2012</option>
<option value="2011"> 2011</option>
<option value="2010"> 2010</option>
<option value="2009"> 2009</option>
<option value="2008"> 2008</option>
<option value="2007"> 2007</option>
<option value="2006"> 2006</option>
<option value="2005"> 2005</option>
<option value="2004"> 2004</option>
<option value="2003"> 2003</option>
<option value="2002"> 2002</option>
<option value="2001"> 2001</option>
<option value="2000"> 2000</option>
<option value="1999"> 1999</option>
<option value="1998"> 1998</option>
<option value="1997"> 1997</option>
<option value="1996"> 1996</option>
<option value="1995"> 1995</option>
<option value="1994"> 1994</option>
<option value="1993"> 1993</option>
<option value="1992"> 1992</option>
<option value="1991"> 1991</option>
<option value="1990"> 1990</option>
<option value="1989"> 1989</option>
<option value="1988"> 1988</option>
<option value="1987"> 1987</option>
<option value="1986"> 1986</option>
<option value="1985"> 1985</option>
<option value="1984"> 1984</option>
<option value="1983"> 1983</option>
<option value="1982"> 1982</option>
<option value="1981"> 1981</option>
<option value="1980"> 1980</option>
<option value="1979"> 1979</option>
<option value="1978"> 1978</option>
<option value="1977"> 1977</option>
<option value="1976"> 1976</option>
<option value="1975"> 1975</option>
<option value="1974"> 1974</option>
<option value="1973"> 1973</option>
<option value="1972"> 1972</option>
<option value="1971"> 1971</option>
<option value="1970"> 1970</option>
<option value="1969"> 1969</option>
<option value="1968"> 1968</option>
<option value="1967"> 1967</option>
<option value="1966"> 1966</option>
<option value="1965"> 1965</option>
<option value="1964"> 1964</option>
<option value="1963"> 1963</option>
<option value="1962"> 1962</option>
<option value="1961"> 1961</option>
<option value="1960"> 1960</option>
<option value="1959"> 1959</option>
<option value="1958"> 1958</option>
<option value="1957"> 1957</option>
<option value="1956"> 1956</option>
<option value="1955"> 1955</option>
<option value="1954"> 1954</option>
<option value="1953"> 1953</option>
<option value="1952"> 1952</option>
<option value="1951"> 1951</option>
<option value="1950"> 1950</option>
<option value="1949"> 1949</option>
<option value="1948"> 1948</option>
<option value="1947"> 1947</option>
<option value="1946"> 1946</option>
<option value="1945"> 1945</option>
<option value="1944"> 1944</option>
<option value="1943"> 1943</option>
<option value="1942"> 1942</option>
<option value="1941"> 1941</option>
<option value="1940"> 1940</option>
<option value="1939"> 1939</option>
<option value="1938"> 1938</option>
<option value="1937"> 1937</option>
<option value="1936"> 1936</option>
<option value="1935"> 1935</option>
<option value="1934"> 1934</option>
<option value="1933"> 1933</option>
<option value="1932"> 1932</option>
<option value="1931"> 1931</option>
<option value="1930"> 1930</option>
<option value="1929"> 1929</option>
<option value="1928"> 1928</option>
<option value="1927"> 1927</option>
<option value="1926"> 1926</option>
<option value="1925"> 1925</option>
<option value="1924"> 1924</option>
<option value="1923"> 1923</option>
<option value="1922"> 1922</option>
<option value="1921"> 1921</option>
<option value="1920"> 1920</option>
<option value="1919"> 1919</option>
<option value="1918"> 1918</option>
<option value="1917"> 1917</option>
<option value="1916"> 1916</option>
<option value="1915"> 1915</option>
<option value="1914"> 1914</option>
<option value="1913"> 1913</option>
<option value="1912"> 1912</option>
<option value="1911"> 1911</option>
<option value="1910"> 1910</option>
<option value="1909"> 1909</option>
<option value="1908"> 1908</option>
<option value="1907"> 1907</option>
<option value="1906"> 1906</option>
<option value="1905"> 1905</option>
<option value="1904"> 1904</option>
<option value="1903"> 1903</option>
<option value="1902"> 1902</option>
<option value="1901"> 1901</option>
</select>
</div>
</div>
</div>
</div>
</fieldset>
<fieldset class="pb-3 pb-md-0 text-center" id="div_deceased_relationship">
<div class="col-md-12">
<span><strong>What is your relationship to your loved one?</strong></span><br>
<select name="deceased_relationship" id="deceased_relationship" class="form-control-lg" style="width:75% !important;margin-left:auto;margin-right:auto;">
<option value="" selected="selected" style="font-size: 14px;">[ Select ] </option>
<option value="N/A" hidden=""></option>
<option value="daughter"> Daughter </option>
<option value="father"> Father </option>
<option value="grandchild"> Grandchild </option>
<option value="legal_representative"> Legal Representative </option>
<option value="mother"> Mother </option>
<option value="sibling"> Sibling </option>
<option value="son"> Son </option>
<option value="spouse"> Spouse </option>
<option value="other "> Other </option>
</select>
</div>
</fieldset>
<fieldset class="pb-3 pb-md-0 text-center" id="div_injured_party_name">
<div class="row">
<div class="col-md-12">
<span>
<strong>What is the injured party's name?</strong>
</span>
<br>
</div>
<div class="row input-group mb-0">
<div class="col-md-12">
<input type="text" class="form-control form-control-lg" id="injured_name" name="injured_name" placeholder="Full Name" pattern="^([a-zA-Z]+\s?\b){2,}" value="" style="width: 100% !important;">
</div>
</div>
</div>
</fieldset>
<fieldset class="pb-3 pb-md-0 text-center" id="div_signature_authority">
<div class="form-check">
<span><strong>Do you have legal authority to sign on their behalf?</strong></span><br>
<input type="radio" class="btn-check" id="signature_authority_yes" name="signature_authority" autocomplete="off" value="1">
<label class="btn btn-primary" for="signature_authority_yes" style="width:100%;border:solid grey 1px;">Yes</label><br>
<input type="radio" class="btn-check" id="signature_authority_no" name="signature_authority" autocomplete="off" value="0">
<label class="btn btn-primary" for="signature_authority_no" style="width:100%;border:solid grey 1px;">No</label>
<input type="radio" class="btn-check" id="signature_authority_na" name="signature_authority" autocomplete="off" value="N/A" hidden="">
</div>
</fieldset>
<fieldset class="pb-3 pb-md-0 text-center" id="div_have_poa">
<div class="form-check">
<span><strong>Do you have a Power of Attorney (POA)?</strong></span><br>
<input type="radio" class="btn-check" id="have_poa_yes" name="have_poa" autocomplete="off" value="1">
<label class="btn btn-primary" for="have_poa_yes" style="width:100%;border:solid grey 1px;">Yes</label><br>
<input type="radio" class="btn-check" id="have_poa_no" name="have_poa" autocomplete="off" value="0">
<label class="btn btn-primary" for="have_poa_no" style="width:100%;border:solid grey 1px;">No</label>
<input type="radio" class="btn-check" id="have_poa_na" name="have_poa" autocomplete="off" value="N/A" hidden="">
</div>
</fieldset>
<fieldset class="pb-3 pb-md-0 text-center" id="div_suffered">
<div class="form-check">
<span><strong>Have you or your loved one suffered harm as a result of water contamination at Camp Lejeune?</strong></span><br>
<input type="radio" class="btn-check" id="suffered_yes" name="suffered" autocomplete="off" value="1">
<label class="btn btn-primary" for="suffered_yes" style="width:100%;border:solid grey 1px;">Yes</label><br>
<input type="radio" class="btn-check" id="suffered_no" name="suffered" autocomplete="off" value="0">
<label class="btn btn-primary" for="suffered_no" style="width:100%;border:solid grey 1px;">No</label>
</div>
</fieldset>
<fieldset class="pb-3 pb-md-0 text-center" id="div_diagnosis_year">
<div class="row">
<span><strong>What year were you/injured party diagnosed with your claimed injury?</strong></span>
<select name="diagnosis_year" id="diagnosis_year" class="form-select form-select-lg mb-3" style="width:75% !important;margin-left:auto!important;margin-right:auto!important;">
<option value="">[Select Year]</option>
<option value="2023">2023</option>
<option value="2022">2022</option>
<option value="2021">2021</option>
<option value="2020">2020</option>
<option value="2019">2019</option>
<option value="2018">2018</option>
<option value="2017">2017</option>
<option value="2016">2016</option>
<option value="2015">2015</option>
<option value="2014">2014</option>
<option value="2013">2013</option>
<option value="2012">2012</option>
<option value="2011">2011</option>
<option value="2010">2010</option>
<option value="2009">2009</option>
<option value="2008">2008</option>
<option value="2007">2007</option>
<option value="2006">2006</option>
<option value="2005">2005</option>
<option value="2004">2004</option>
<option value="2003">2003</option>
<option value="2002">2002</option>
<option value="2001">2001</option>
<option value="2000">2000</option>
<option value="1999">1999</option>
<option value="1998">1998</option>
<option value="1997">1997</option>
<option value="1996">1996</option>
<option value="1995">1995</option>
<option value="1994">1994</option>
<option value="1993">1993</option>
<option value="1992">1992</option>
<option value="1991">1991</option>
<option value="1990">1990</option>
<option value="1989">1989</option>
<option value="1988">1988</option>
<option value="1987">1987</option>
<option value="1986">1986</option>
<option value="1985">1985</option>
<option value="1984">1984</option>
<option value="1983">1983</option>
<option value="1982">1982</option>
<option value="1981">1981</option>
<option value="1980">1980</option>
<option value="1979">1979</option>
<option value="1978">1978</option>
<option value="1977">1977</option>
<option value="1976">1976</option>
<option value="1975">1975</option>
<option value="1974">1974</option>
<option value="1973">1973</option>
<option value="1972">1972</option>
<option value="1971">1971</option>
<option value="1970">1970</option>
<option value="1969">1969</option>
<option value="1968">1968</option>
<option value="1967">1967</option>
<option value="1966">1966</option>
<option value="1965">1965</option>
<option value="1964">1964</option>
<option value="1963">1963</option>
<option value="1962">1962</option>
<option value="1961">1961</option>
<option value="1960">1960</option>
<option value="1959">1959</option>
<option value="1958">1958</option>
<option value="1957">1957</option>
<option value="1956">1956</option>
<option value="1955">1955</option>
<option value="1954">1954</option>
<option value="1953">1953</option>
</select>
</div>
</fieldset>
<fieldset class="pb-3 pb-md-0 text-center" id="div_diagnosis_location">
<div class="row">
<span><strong>What hospital/doctor and city & state were you/injured party diagnosed in?</strong></span>
<div class="row input-group mb-0">
<div class="col-md-6">
<input type="text" class="form-control form-control-lg " id="diagnosis_hospital" name="diagnosis_hospital" placeholder="Hospital Name/Doctor" value="" style="width: 100% !important;">
</div>
<div class="col-md-3">
<input type="text" class="form-control form-control-lg " id="diagnosis_city" name="diagnosis_city" placeholder="City" value="" style="width: 100% !important;">
</div>
<div class="col-md-3">
<select type="text" class="form-control-lg" id="diagnosis_state" name="diagnosis_state" placeholder="State" value="" style="width: 100% !important;">
<option value="">State</option>
<option value="AL">Alabama</option>
<option value="AK">Alaska</option>
<option value="AZ">Arizona</option>
<option value="AR">Arkansas</option>
<option value="CA">California</option>
<option value="CO">Colorado</option>
<option value="CT">Connecticut</option>
<option value="DE">Delaware</option>
<option value="DC">District Of Columbia</option>
<option value="FL">Florida</option>
<option value="GA">Georgia</option>
<option value="HI">Hawaii</option>
<option value="ID">Idaho</option>
<option value="IL">Illinois</option>
<option value="IN">Indiana</option>
<option value="IA">Iowa</option>
<option value="KS">Kansas</option>
<option value="KY">Kentucky</option>
<option value="LA">Louisiana</option>
<option value="ME">Maine</option>
<option value="MD">Maryland</option>
<option value="MA">Massachusetts</option>
<option value="MI">Michigan</option>
<option value="MN">Minnesota</option>
<option value="MS">Mississippi</option>
<option value="MO">Missouri</option>
<option value="MT">Montana</option>
<option value="NE">Nebraska</option>
<option value="NV">Nevada</option>
<option value="NH">New Hampshire</option>
<option value="NJ">New Jersey</option>
<option value="NM">New Mexico</option>
<option value="NY">New York</option>
<option value="NC">North Carolina</option>
<option value="ND">North Dakota</option>
<option value="OH">Ohio</option>
<option value="OK">Oklahoma</option>
<option value="OR">Oregon</option>
<option value="PA">Pennsylvania</option>
<option value="RI">Rhode Island</option>
<option value="SC">South Carolina</option>
<option value="SD">South Dakota</option>
<option value="TN">Tennessee</option>
<option value="TX">Texas</option>
<option value="UT">Utah</option>
<option value="VT">Vermont</option>
<option value="VA">Virginia</option>
<option value="WA">Washington</option>
<option value="WV">West Virginia</option>
<option value="WI">Wisconsin</option>
<option value="WY">Wyoming</option>
</select>
</div>
</div>
</div>
</fieldset>
<fieldset class="pb-3 pb-md-0" id="div_reason">
<div class="row">
<div class="col-md-12">
<span><strong>Please select the reason for being at Camp Lejeune:</strong></span><br>
<select name="reason" id="reason" class="form-control-lg" style="width:75% !important;margin-left:auto;margin-right:auto">
<option value="" selected="selected" style="">[ Select ] </option>
<option value="lived"> Lived </option>
<option value="served"> Served </option>
<option value="worked"> Worked </option>
</select>
</div>
</div>
</fieldset>
<fieldset class="pb-1 pb-md-0" id="div_unit_lived">
<div class="row">
<div class="col-md-12">
<span><strong>What barracks/housing unit did you reside at Camp Lejeune?</strong></span><br>
<select name="unit_lived" id="unit_lived" class="form-control-lg" style="width:75% !important;margin-left:auto;margin-right:auto">
<option value="" selected="selected" style="">[ Select ] </option>
<option value="N/A" hidden=""></option>
<option value="bachelor_housing"> Bachelor Housing </option>
<option value="berkeley_manor"> Berkeley Manor </option>
<option value="camp_knox"> Camp Knox </option>
<option value="hospital_point"> Hospital Point </option>
<option value="midway_park"> Midway Park </option>
<option value="paradise_point"> Paradise Point </option>
<option value="tarawa_terrace"> Tarawa Terrace </option>
<option value="wadkins_village"> Wadkins Village </option>
</select>
</div>
</div>
</fieldset>
<fieldset class="pb-3 pb-md-0" id="div_length_lived">
<div class="form-check">
<span><strong>Were you at Camp Lejeune for at least 30 days?</strong></span><br>
<input type="radio" class="btn-check length_lived" id="length_lived_yes" name="length_lived" autocomplete="off" value="1">
<label class="btn btn-primary" for="length_lived_yes" style="width:100%;border:solid grey 1px;">Yes</label><br>
<input type="radio" class="btn-check used_talcum" id="length_lived_no" name="length_lived" autocomplete="off" value="0">
<label class="btn btn-primary" for="length_lived_no" style="width:100%;border:solid grey 1px;">No</label>
</div>
</fieldset>
<fieldset class="pb-1 pb-md-0" id="div_first_year">
<div class="col-md-12">
<span><strong>Please select you or your loved one's first year at Camp Lejeune:</strong></span><br>
<select name="first_year" id="first_year" vtype="not_empty" vclass="not_show" class="form-select form-control-lg" style="width:75% !important;margin-left:auto!important;margin-right:auto!important;">
<option value="">[Select Year]</option>
<option value="2023">2023</option>
<option value="2022">2022</option>
<option value="2021">2021</option>
<option value="2020">2020</option>
<option value="2019">2019</option>
<option value="2018">2018</option>
<option value="2017">2017</option>
<option value="2016">2016</option>
<option value="2015">2015</option>
<option value="2014">2014</option>
<option value="2013">2013</option>
<option value="2012">2012</option>
<option value="2011">2011</option>
<option value="2010">2010</option>
<option value="2009">2009</option>
<option value="2008">2008</option>
<option value="2007">2007</option>
<option value="2006">2006</option>
<option value="2005">2005</option>
<option value="2004">2004</option>
<option value="2003">2003</option>
<option value="2002">2002</option>
<option value="2001">2001</option>
<option value="2000">2000</option>
<option value="1999">1999</option>
<option value="1998">1998</option>
<option value="1997">1997</option>
<option value="1996">1996</option>
<option value="1995">1995</option>
<option value="1994">1994</option>
<option value="1993">1993</option>
<option value="1992">1992</option>
<option value="1991">1991</option>
<option value="1990">1990</option>
<option value="1989">1989</option>
<option value="1988">1988</option>
<option value="1987">1987</option>
<option value="1986">1986</option>
<option value="1985">1985</option>
<option value="1984">1984</option>
<option value="1983">1983</option>
<option value="1982">1982</option>
<option value="1981">1981</option>
<option value="1980">1980</option>
<option value="1979">1979</option>
<option value="1978">1978</option>
<option value="1977">1977</option>
<option value="1976">1976</option>
<option value="1975">1975</option>
<option value="1974">1974</option>
<option value="1973">1973</option>
<option value="1972">1972</option>
<option value="1971">1971</option>
<option value="1970">1970</option>
<option value="1969">1969</option>
<option value="1968">1968</option>
<option value="1967">1967</option>
<option value="1966">1966</option>
<option value="1965">1965</option>
<option value="1964">1964</option>
<option value="1963">1963</option>
<option value="1962">1962</option>
<option value="1961">1961</option>
<option value="1960">1960</option>
<option value="1959">1959</option>
<option value="1958">1958</option>
<option value="1957">1957</option>
<option value="1956">1956</option>
<option value="1955">1955</option>
<option value="1954">1954</option>
<option value="1953">1953</option>
<option value="1952">1952</option>
<option value="1951">1951</option>
<option value="1950">1950</option>
<option value="1949">1949</option>
<option value="1948">1948</option>
<option value="1947">1947</option>
<option value="1946">1946</option>
<option value="1945">1945</option>
<option value="1944">1944</option>
<option value="1943">1943</option>
<option value="1942">1942</option>
</select>
</div>
</fieldset>
<fieldset class="pb-1 pb-md-0" id="div_last_year">
<div class="col-md-12">
<span><strong>Please select you or your loved one's last year at Camp Lejeune:</strong></span><br>
<select name="last_year" id="last_year" vtype="not_empty" vclass="not_show" class="form-select form-control-lg" style="width:75% !important;margin-left:auto!important;margin-right:auto!important;">
<option value="">[Select Year]</option>
<option value="2023">2023</option>
<option value="2022">2022</option>
<option value="2021">2021</option>
<option value="2020">2020</option>
<option value="2019">2019</option>
<option value="2018">2018</option>
<option value="2017">2017</option>
<option value="2016">2016</option>
<option value="2015">2015</option>
<option value="2014">2014</option>
<option value="2013">2013</option>
<option value="2012">2012</option>
<option value="2011">2011</option>
<option value="2010">2010</option>
<option value="2009">2009</option>
<option value="2008">2008</option>
<option value="2007">2007</option>
<option value="2006">2006</option>
<option value="2005">2005</option>
<option value="2004">2004</option>
<option value="2003">2003</option>
<option value="2002">2002</option>
<option value="2001">2001</option>
<option value="2000">2000</option>
<option value="1999">1999</option>
<option value="1998">1998</option>
<option value="1997">1997</option>
<option value="1996">1996</option>
<option value="1995">1995</option>
<option value="1994">1994</option>
<option value="1993">1993</option>
<option value="1992">1992</option>
<option value="1991">1991</option>
<option value="1990">1990</option>
<option value="1989">1989</option>
<option value="1988">1988</option>
<option value="1987">1987</option>
<option value="1986">1986</option>
<option value="1985">1985</option>
<option value="1984">1984</option>
<option value="1983">1983</option>
<option value="1982">1982</option>
<option value="1981">1981</option>
<option value="1980">1980</option>
<option value="1979">1979</option>
<option value="1978">1978</option>
<option value="1977">1977</option>
<option value="1976">1976</option>
<option value="1975">1975</option>
<option value="1974">1974</option>
<option value="1973">1973</option>
<option value="1972">1972</option>
<option value="1971">1971</option>
<option value="1970">1970</option>
<option value="1969">1969</option>
<option value="1968">1968</option>
<option value="1967">1967</option>
<option value="1966">1966</option>
<option value="1965">1965</option>
<option value="1964">1964</option>
<option value="1963">1963</option>
<option value="1962">1962</option>
<option value="1961">1961</option>
<option value="1960">1960</option>
<option value="1959">1959</option>
<option value="1958">1958</option>
<option value="1957">1957</option>
<option value="1956">1956</option>
<option value="1955">1955</option>
<option value="1954">1954</option>
<option value="1953">1953</option>
<option value="1952">1952</option>
<option value="1951">1951</option>
<option value="1950">1950</option>
<option value="1949">1949</option>
<option value="1948">1948</option>
<option value="1947">1947</option>
<option value="1946">1946</option>
<option value="1945">1945</option>
<option value="1944">1944</option>
<option value="1943">1943</option>
<option value="1942">1942</option>
</select>
</div>
</fieldset>
<fieldset class="pb-1 pb-md-0" id="div_dob">
<div class="row">
<div class="col-md-12">
<span><strong>Please enter injured party date of birth.</strong></span><br>
<div class="row">
<div class="col-md-4">
<select id="edit_dob_month" name="edit_dob_month" class="form-select form-dob-select" vtype="not_empty" style="width: 100% !important;">
<option value="" selected="selected">Month</option>
<option value="01"> Jan</option>
<option value="02"> Feb</option>
<option value="03"> Mar</option>
<option value="04"> Apr</option>
<option value="05"> May</option>
<option value="06"> Jun</option>
<option value="07"> Jul</option>
<option value="08"> Aug</option>
<option value="09"> Sep</option>
<option value="10"> Oct</option>
<option value="11"> Nov</option>
<option value="12"> Dec</option>
</select>
</div>
<div class="col-md-4">
<select id="edit_dob_day" name="edit_dob_day" class="form-select form-dob-select" vtype="not_empty" style="width: 100% !important;">
<option value="" selected="selected">Day</option>
<option value="01"> 1</option>
<option value="02"> 2</option>
<option value="03"> 3</option>
<option value="04"> 4</option>
<option value="05"> 5</option>
<option value="06"> 6</option>
<option value="07"> 7</option>
<option value="08"> 8</option>
<option value="09"> 9</option>
<option value="10"> 10</option>
<option value="11"> 11</option>
<option value="12"> 12</option>
<option value="13"> 13</option>
<option value="14"> 14</option>
<option value="15"> 15</option>
<option value="16"> 16</option>
<option value="17"> 17</option>
<option value="18"> 18</option>
<option value="19"> 19</option>
<option value="20"> 20</option>
<option value="21"> 21</option>
<option value="22"> 22</option>
<option value="23"> 23</option>
<option value="24"> 24</option>
<option value="25"> 25</option>
<option value="26"> 26</option>
<option value="27"> 27</option>
<option value="28"> 28</option>
<option value="29"> 29</option>
<option value="30"> 30</option>
<option value="31"> 31</option>
</select>
</div>
<div class="col-md-4">
<select id="edit_dob_year" name="edit_dob_year" class="form-select form-dob-select" vtype="not_empty" style="width: 100% !important;">
<option value="">Year</option>
<option value="2005"> 2005</option>
<option value="2004"> 2004</option>
<option value="2003"> 2003</option>
<option value="2002"> 2002</option>
<option value="2001"> 2001</option>
<option value="2000"> 2000</option>
<option value="1999"> 1999</option>
<option value="1998"> 1998</option>
<option value="1997"> 1997</option>
<option value="1996"> 1996</option>
<option value="1995"> 1995</option>
<option value="1994"> 1994</option>
<option value="1993"> 1993</option>
<option value="1992"> 1992</option>
<option value="1991"> 1991</option>
<option value="1990"> 1990</option>
<option value="1989"> 1989</option>
<option value="1988"> 1988</option>
<option value="1987"> 1987</option>
<option value="1986"> 1986</option>
<option value="1985"> 1985</option>
<option value="1984"> 1984</option>
<option value="1983"> 1983</option>
<option value="1982"> 1982</option>
<option value="1981"> 1981</option>
<option value="1980"> 1980</option>
<option value="1979"> 1979</option>
<option value="1978"> 1978</option>
<option value="1977"> 1977</option>
<option value="1976"> 1976</option>
<option value="1975"> 1975</option>
<option value="1974"> 1974</option>
<option value="1973"> 1973</option>
<option value="1972"> 1972</option>
<option value="1971"> 1971</option>
<option value="1970"> 1970</option>
<option value="1969"> 1969</option>
<option value="1968"> 1968</option>
<option value="1967"> 1967</option>
<option value="1966"> 1966</option>
<option value="1965"> 1965</option>
<option value="1964"> 1964</option>
<option value="1963"> 1963</option>
<option value="1962"> 1962</option>
<option value="1961"> 1961</option>
<option value="1960"> 1960</option>
<option value="1959"> 1959</option>
<option value="1958"> 1958</option>
<option value="1957"> 1957</option>
<option value="1956"> 1956</option>
<option value="1955"> 1955</option>
<option value="1954"> 1954</option>
<option value="1953"> 1953</option>
<option value="1952"> 1952</option>
<option value="1951"> 1951</option>
<option value="1950"> 1950</option>
<option value="1949"> 1949</option>
<option value="1948"> 1948</option>
<option value="1947"> 1947</option>
<option value="1946"> 1946</option>
<option value="1945"> 1945</option>
<option value="1944"> 1944</option>
<option value="1943"> 1943</option>
<option value="1942"> 1942</option>
<option value="1941"> 1941</option>
<option value="1940"> 1940</option>
<option value="1939"> 1939</option>
<option value="1938"> 1938</option>
<option value="1937"> 1937</option>
<option value="1936"> 1936</option>
<option value="1935"> 1935</option>
<option value="1934"> 1934</option>
<option value="1933"> 1933</option>
<option value="1932"> 1932</option>
<option value="1931"> 1931</option>
<option value="1930"> 1930</option>
<option value="1929"> 1929</option>
<option value="1928"> 1928</option>
<option value="1927"> 1927</option>
<option value="1926"> 1926</option>
<option value="1925"> 1925</option>
<option value="1924"> 1924</option>
<option value="1923"> 1923</option>
<option value="1922"> 1922</option>
<option value="1921"> 1921</option>
<option value="1920"> 1920</option>
<option value="1919"> 1919</option>
<option value="1918"> 1918</option>
<option value="1917"> 1917</option>
<option value="1916"> 1916</option>
<option value="1915"> 1915</option>
<option value="1914"> 1914</option>
<option value="1913"> 1913</option>
<option value="1912"> 1912</option>
<option value="1911"> 1911</option>
<option value="1910"> 1910</option>
<option value="1909"> 1909</option>
<option value="1908"> 1908</option>
<option value="1907"> 1907</option>
<option value="1906"> 1906</option>
<option value="1905"> 1905</option>
<option value="1904"> 1904</option>
<option value="1903"> 1903</option>
<option value="1902"> 1902</option>
<option value="1901"> 1901</option>
</select>
</div>
</div>
</div>
</div>
</fieldset>
<fieldset class="pb-3 pb-md-0" id="div_administrative_claim">
<div class="form-check">
<span><strong>Have you filed an administrative claim for Camp Lejeune benefits?</strong></span><br>
<input type="radio" class="btn-check" id="administrative_claim_yes" name="administrative_claim" autocomplete="off" value="1">
<label class="btn btn-primary" for="administrative_claim_yes" style="width:100%;border:solid grey 1px;">Yes</label><br>
<input type="radio" class="btn-check" id="administrative_claim_no" name="administrative_claim" autocomplete="off" value="0">
<label class="btn btn-primary" for="administrative_claim_no" style="width:100%;border:solid grey 1px;">No</label>
</div>
</fieldset>
<fieldset class="pb-3 pb-md-0" id="div_claim_date">
<div class="row">
<span><strong>What date did you file?</strong></span>
<div class="row input-group mb-0">
<div class=" col-md-12">
<input type="text" class="form-control form-control-lg " id="claim_date" name="claim_date" placeholder="MM/DD/YYYY" value="">
</div>
</div>
</div>
</fieldset>
<fieldset class="pb-3 pb-md-0" id="div_medical_records">
<div class="form-check">
<span>
<strong>Do you have a copy of medical records in your possession concerning the harm?</strong>
</span>
<br>
<input type="radio" class="btn-check" id="medical_records_yes" name="medical_records" autocomplete="off" value="1">
<label class="btn btn-primary" for="medical_records_yes" style="width:100%;border:solid grey 1px;">Yes</label><br>
<input type="radio" class="btn-check" id="medical_records_no" name="medical_records" autocomplete="off" value="0">
<label class="btn btn-primary" for="medical_records_no" style="width:100%;border:solid grey 1px;">No</label>
</div>
</fieldset>
<fieldset class="pb-3 pb-md-0" id="div_future_concern">
<div class="form-check">
<span>
<strong>Are you concerned about developing a medical condition in the future?</strong>
</span>
<br>
<input type="radio" class="btn-check" id="future_concern_yes" name="future_concern" autocomplete="off" value="1">
<label class="btn btn-primary" for="future_concern_yes" style="width:100%;border:solid grey 1px;">Yes</label><br>
<input type="radio" class="btn-check" id="future_concern_no" name="future_concern" autocomplete="off" value="0">
<label class="btn btn-primary" for="future_concern_no" style="width:100%;border:solid grey 1px;">No</label>
</div>
</fieldset>
<fieldset class="pb-3 pb-md-0" id="div_bankruptcy">
<div class="form-check">
<span><strong>Have you ever filed for bankruptcy?</strong></span><br>
<input type="radio" class="btn-check" id="bankruptcy_yes" name="bankruptcy" autocomplete="off" value="1">
<label class="btn btn-primary" for="bankruptcy_yes" style="width:100%;border:solid grey 1px;">Yes</label><br>
<input type="radio" class="btn-check" id="bankruptcy_no" name="bankruptcy" autocomplete="off" value="0">
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Accessibility ✗ - Close Add Keyboard Tabbing Turn off Animations color contrast Gray Display Increase Contrast Reverse Contrast size of text Increase Text Size Decrease Text Size Remove Font highlighting content Underline Links Underline Titles Images Titles zoom in Large Cursor Large Cursor Zoom Screen Terms Report an Issue Reset Settings Accessibility ✗ - Close Add Keyboard Tabbing Turn off Animations color contrast Gray Display Increase Contrast Reverse Contrast size of text Increase Text Size Decrease Text Size Remove Font highlighting content Underline Links Underline Titles Images Titles zoom in Large Cursor Large Cursor Zoom Screen Terms Report an Issue Reset Settings CAMP LEJEUNE WATER CONTAMINATION LAWSUITS ARE NOW BEING FILED! CAMP LEJEUNE JUSTICE ACT PASSES U.S. SENATE AS PART OF PACT ACT AS OF AUGUST 10TH, 2022* * SIGNS & SYMPTOMS -------------------------------------------------------------------------------- * BLADDER CANCER * CARDIAC BIRTH DEFECTS * FEMALE INFERTILITY * HEPATIC STEATOSIS * MISCARRIAGE * NEUROBEHAVIORAL EFFECTS * OTHER CANCERS * AND MORE… CAMP LEJEUNE WATER CONTAMINATION LAWSUITS ARE NOW BEING FILED! Camp Lejeune Justice Act passes U.S. Senate as part of PACT Act as of August 10th, 2022* TIME IS LIMITED FILL OUT THE FORM BELOW TO GET YOUR FREE CLAIM REVIEW YOU MAY BE ENTITLED TO FINANCIAL COMPENSATION! You may be entitled to financial compensation! 0% Hi there. I can help you see if you qualify for a Camp Lejeune claim! The information you provide me is confidential and will only be shared with the lawyers I work with. Is the affected individual you or a loved one? Myself Loved One Did you or a loved one Serve, Live or Work at Marine Corps Base Camp Lejeune between Aug. 1953 and Dec. 1987? Yes No **Diagnosis is needed to determine if you have a valid case against Camp Lejeune Have you or a loved one been diagnosed with: [ Select ] Acute Lymphoblastic Leukemia (ALL) Acute Myeloid Leukemia (AML) Amyotrophic Lateral Sclerosis (ALS) Anal Cancer Appendix cancer Aplastic Anemia Atrial Septal Defect Bile duct cancer Birth defects/malformation Bladder Cancer Bone Cancer Brain CNS Cancers Breast Cancer Born with Cardiac Birth Defects Cervical Cancer Central nervous system cancer Childhood Cancers Chronic Lymphocytic Leukemia (CLL) Chronic Myelogenous Leukemia (CML) Colorectal cancer Dental Issues/Tooth Early-onset dementia Esophageal Cancer Extragonadal Germ Cell cancer Eye Cancer Fallopian Tube Cancer Female Infertility Fetal Death Gallbladder cancer Gastrointestinal Cancer Germ Cell Cancer Gestational Trophoblastic disease Hairy Cell Leukemia Head and Neck cancer Heart Attack Hepatic Steatosis Hodgkins Lymphoma Infertility Intestinal cancer Kidney Cancer Kidney Disease Laryngeal Cancer Leukemia Liver Cancer Lung Cancer Metastatic cancer Miscarriage Multiple Myeloma Multiple Sclerosis (MS) Mycosis Fungoides Myelodysplastic Syndromes (MDS) Neurobehavioral Effects Non-Hodgkin's Lymphoma (NHL) Ovarian cancer Pancreatic Cancer Parkinson's Disease Patent Ductus Arteriosus Primary CNS Lymphoma Prostate Cancer Rectal Cancer Renal Toxicity Scleroderma Sinus cancer Soft tissue sarcoma Spinal cancer Stomach Cancer Testicular Cancer Tetralogy of Fallot Thyroid Cancer Transposition of the Great Arteries Uterine Cancer Vascular Tumors Ventricular Septal Defect Other None Did your mother reside at CLJ when you were born, or was your mother pregnant with you when she resided at Camp Lejeune? Yes No Do you currently have another law firm representing you on this claim? Yes No Please select the gender of the injured individual: Female Male Your Claim Results Are Ready ! Receive your claim results by submitting your information so we can connect you with a lawyer. You May Have A Claim! Based on the information you provided it appears you may have a claim. We just have a few more questions before we connect you with one of our lawyers. Is the injured party deceased? Yes No When did your loved one pass away? Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 What is your relationship to your loved one? [ Select ] Daughter Father Grandchild Legal Representative Mother Sibling Son Spouse Other What is the injured party's name? Do you have legal authority to sign on their behalf? Yes No Do you have a Power of Attorney (POA)? Yes No Have you or your loved one suffered harm as a result of water contamination at Camp Lejeune? Yes No What year were you/injured party diagnosed with your claimed injury? [Select Year] 20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953 What hospital/doctor and city & state were you/injured party diagnosed in? State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Please select the reason for being at Camp Lejeune: [ Select ] Lived Served Worked What barracks/housing unit did you reside at Camp Lejeune? [ Select ] Bachelor Housing Berkeley Manor Camp Knox Hospital Point Midway Park Paradise Point Tarawa Terrace Wadkins Village Were you at Camp Lejeune for at least 30 days? Yes No Please select you or your loved one's first year at Camp Lejeune: [Select Year] 2023202220212020201920182017201620152014201320122011201020092008200720062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942 Please select you or your loved one's last year at Camp Lejeune: [Select Year] 2023202220212020201920182017201620152014201320122011201020092008200720062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942 Please enter injured party date of birth. Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 Have you filed an administrative claim for Camp Lejeune benefits? Yes No What date did you file? Do you have a copy of medical records in your possession concerning the harm? Yes No Are you concerned about developing a medical condition in the future? Yes No Have you ever filed for bankruptcy? Yes No Are you currently in bankruptcy? Yes No Please add any additional information that will help us determine if the case qualifies for compensation: Case Notes: By clicking the “Next” button, you certify that you have provided your legal name and your own phone number, you agree to the Terms and Conditions and Privacy Policy and authorize Lawsuit-Winning and its partners to contact you by email or at the phone number you entered using automated technology including recurring auto-dialers, pre-recorded messages, and text messages, even if your phone is a mobile number or is currently listed on any state, federal, or corporate “Do Not Call” list. You understand that your telephone company may impose charges on you for these contacts, and that you can revoke this consent at any time. For SMS campaigns Text STOP to cancel and HELP for help. Message and data rates may apply. By clicking the “Next” button and submitting this form, I affirm that I have read and agree to this Site’s Terms and Conditions (including the arbitration provision and the E-SIGN consent) and Privacy Policy. FIND YOURSELF A LAWYER THAT WILL FIGHT FOR YOU AND YOUR RIGHTS! Receive the Compensation You Deserve! FREE No Obligation Consultation - Pay Nothing! Your Contact Information and Your Claim are Confidential! Get Help Now! You may BE ENTITLED TO FINANCIAL COMPENSATION for your pain and suffering. You probably didn't know you could be owed money for your situation, and it is time to speak up! DON'T LET YOU OR YOUR FAMILY SUFFER in silence. If you have taken any of these, had any of these surgeries, submit your information for a FREE CLAIM REVIEW » ABOUT CAMP LEJEUNE WATER CONTAMINATION LAWSUITS -------------------------------------------------------------------------------- Camp Lejeune is a massive Marine Corps base and military training facility that covers nearly 250 square miles in Onslow County, North Carolina. Camp Lejeune was first opened in 1942. It has been used as both a base of operations for the Marine Corps and a military operations and training facility used by various branches of the armed forces. Since its founding in 1942, Camp Lejeune has been a temporary or permanent home for thousands of military service members and their families. It has also been a home or place of work for thousands more civilian employees and contractors. Camp Lejeune had its own public water system to supply these soldiers and civilians with potable water. Routine water testing in 1982 found that drinking water sources at Camp Lejeune were contaminated with benzene, trichloroethylene (TCE), tetrachloroethylene, or perchloroethylene (PCE), and vinyl chloride (VC), all of which are known to be carcinogenic or harmful to humans. Contamination of water was documented at up to 300 times acceptable levels in some cases. The main chemicals involved were volatile organic compounds (VOCs), however, more than 70 chemicals have been identified as contaminants at Camp Lejeune. Camp Lejeune Justice Act of 2022: The Camp Lejeune Justice Act of 2022 is a bipartisan bill intended to ensure that individuals – veterans, their family members or other individuals living or working at the base between 1953 and 1987 – who were harmed by water contamination at Camp Lejeune receive fair compensation. Many of these individuals have had their claims inappropriately denied or delayed, resulting in additional harm. The Bill is making its way through Congress as part of the Honoring Our PACT Act of 2022, which passed the U.S. House of Representatives on March 4, 2022. The Act will permit people who worked, lived, or were exposed in-utero, to contaminated water at Camp Lejeune between 1953 and 1987, to file a claim in U.S. federal court. June 16, 2022, Camp Lejeune Legislative Update: Republicans and Democrats came together today in a resounding 84-16 vote for the 19 million veterans in the U.S. today, we look forward to working with all lawyers and legal vendors who share the goal of settling the debts owed to the millions of veterans who served and sacrificed on our country’s behalf. -------------------------------------------------------------------------------- SIGNS & SYMPTOMS -------------------------------------------------------------------------------- For over 30 years, Marines and personnel of any branch of the armed forces and their families stationed at Camp Lejeune's main base, barracks, family, temporary housing, Tarawa Terrace, and Hadnot Point drank and bathed in water contaminated with toxins at concentrations from 240 to 3400 times levels permitted by safety standards. Camp Lejeune water contamination sources included leaking underground water storage tanks and waste disposal sites. The contaminated wells were mostly closed by February 1985; however, those who had been exposed have faced cancer and other serious health problems related to the chemicals. Side effects and Health Conditions include, but are not limited to: * Bladder Cancer * Breast Cancer * Cardiac Birth Defects * Esophageal Cancer * Esophageal Cancer * Hepatic Steatosis * Kidney Cancer * Leukemia * Liver Cancer * Lung Cancer * Miscarriage * Multiple Myeloma * Myelodysplastic Syndromes (MDS) * Neurobehavioral Effects * Non-Hodgkin's Lymphoma (NHL) * Parkinson's Disease * Renal Toxicity * Scleroderma TAKE ACTION -------------------------------------------------------------------------------- Most Camp Lejeune victims have previously not had access to the kind of compensation needed to take care of their and their families' injuries. The Camp Lejeune Justice Act of 2022 may now allow victims to recover significant compensation. If you lived or worked at Camp Lejeune between 1953 and 1987 and developed cancer or another serious illness; you need to speak up! You might be eligible for financial compensation for your pain and suffering. Don’t suffer in silence. Fill out a no-cost claim review to see if you are eligible to receive compensation. – complete the free and easy claim review form today . Get Help Now! IN THE NEWS -------------------------------------------------------------------------------- Lawsuit Information Center - Camp Lejeune Lawsuit - June 16, 2022 Copyright © 2023, Lawsuit-Winning Privacy Policy | Terms & Conditions | CA Residents Only - Do Not Sell My Info | California Privacy | Partners | Unsubscribe Lawsuit-Winning is devoted to helping consumers who may have been injured by prescription medications, financial fraud, automobile recalls, and various other issues where they could seek legal representation. THIS IS AN ADVERTISEMENT. 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