PFAS Exposure Claim Intake Form

PFAS Exposure Claim Intake Form
Submit your details to initiate a claim regarding potential exposure to PFAS chemicals.
Full Name*
First NameLast Name
Email Address*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Current Address*
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
MyselfOn behalf of someone else
Location of PFAS Exposure (if different from your current address)*
Drinking waterWorkplace exposureFood contaminationEnvironmental/soilOther
Approximate dates of exposure (start and end dates, if known)
Describe any health symptoms or medical diagnoses you believe are related to PFAS exposure*
YesNo
Please upload any supporting documents (e.g., test results, medical records, water reports, etc.)
Cancelof
Relationship to exposure site*
Additional comments or information
Should be Empty: