Foodborne Illness Lawsuit Claim Intake Form
Use this form to share basic details about a possible foodborne illness claim so the intake team can review the incident and follow up.
Claimant Information
Full Name
*
First Name
Middle Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Preferred Contact Method
*
Phone
Email
Incident and Illness Details
Date Food Was Consumed
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Approximate Date Symptoms Began
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Restaurant/Store or Food Source Name
*
City and State Where Food Was Purchased or Eaten
*
Brief Description of Suspected Food Item and Symptoms Experienced
*
Potential Claim Follow-Up
Did you visit a doctor, urgent care, or hospital for this illness?
*
Doctor
Urgent Care
Hospital
No
Prefer not to say
Do you have medical records or receipts available to share?
*
Yes
No
Unsure
Best next step for follow-up
*
Review my claim and contact me
Request records and receipts
Schedule a call
I prefer email only
Submit Claim
Should be Empty: