Trichloroethylene Case Inquiry Form

* denotes required fields
Personal Information
* Name
* Address
City
State
Zip Code
Daytime Phone Number
Evening Phone
Mobile Phone
* E-mail Address
   
Case Information
Were you exposed to Trichloroethylene at work?
 
Yes
No
Were you exposed to Trichloroethylene in drinking water?
 
Yes
No
Were you exposed to Trichloroethylene in groundwater?
 
Yes
No
Describe your Trichloroethylene injury:
 
What Cancer or other disease do you believe was caused by Trichloroethylene:
 
Has anyone in your community had similar experiences with Trichloroethylene?
 
Additional Comments & Questions:
 
 
* By typing "agree" into the below box you are confirming that you wish to send your information to Williams Cuker Berezofsky.