Thank you for your inquiry. Please complete the questionnaire that follows the text of this message regarding your possible participation in an "Agent Orange" lawsuit. If you return the questionnaire to us electronically, we will review your information and update you as soon as possible as to the litigation. If you can’t submit it by email, you may also print the form out and submit it by mail – however it may take longer to respond to you. Thank you again very much for your time and interest.
Sincerely,
Gerson H. Smoger
3175 Monterey Blvd., Ste. 300
Oakland, CA 94602
| Name | AGENT ORANGE QUESTIONNAIRE (please just submit the answers)
| Name | |
| Street Address | |
| Address (cont.) | |
| City | |
| State/Province | |
| Zip/Postal Code | |
| Home Phone |
|
| Work Phone | |
| Cell Phone | |
| Fax | |
| Claimant's Date of Birth | |
| Social Security # | |
| Dates of Viet Nam Service | |
| Branch of Service and Rank | |
| Briefly describe where you served, your duties, and where you believe you might have been exposed to herbicides, including Agent Orange: |
|
| What Agent Orange related conditions are you suffering from (If you have cancer please describe the cell type and location): |
|
| When were you diagnosed
with each?
|
|
| Please list any family members related by blood who have suffered or are suffering from the medical conditions you describe above? |
|
| Have you smoked? How many
packs per day and for what period of time?
|
|
| Are you currently
receiving or seeking VA or SS disability? When did you first apply?
|
|
| Have you made a claim for Veteran’s benefits related to your Agent Orange exposure? Has the claim been approved or rejected? When was it approved or rejected? |
|
| Were you aware of or did you participate in the original Agent Orange lawsuit or settlement? Please describe? |
|
| Are you or have you been 100% disabled? If so, when were you first 100% disabled and for what periods of time? |
|
| Please feel free to add any additional comments you would like to make, or ask any questions you might have and we will get back to you. |
|
| Please fill in your EMAIL address |
AGENT ORANGE QUESTIONNAIRE (if you need to send it in by mail)
Name:
Address:
City:
State:
Zip:
Home Phone:
Cell Phone:
Work Phone:
Fax:
Email:
Claimant's Date of Birth:
Place of Birth:
Social Security #:
Please identify two individuals (relatives or friends) who will always know where to contact you
and do NOT reside with you:
Name:
Address:
Phone Number:
Email:
Dates of Viet Nam Service:
Branch of Service and rank:
Briefly describe where you served, your duties, and where you believe you might have been exposed to herbicides, including Agent Orange:
What Agent Orange related conditions are you suffering from (If you have cancer please describe the cell type and location):
When were you diagnosed with each?
Please list any family members related by blood who have suffered or are suffering from the medical conditions you describe above?
Have you smoked? How many packs per day and for what period of time?
Are you currently receiving or seeking VA or SS disability? When did you first apply?
Have you made a claim for Veteran’s benefits related to your Agent Orange exposure? Has the claim been approved or rejected? When was it approved or rejected?
Were you aware of or did you participate in the original Agent Orange lawsuit or settlement? Please describe?
Are you or have you been 100% disabled?
If so, when were you first 100% disabled and for what periods of time?
Please feel free to add any additional comments you would like to make, or ask any questions you might have and we will get back to you.
