Benzene Attorney Instant Answer Service

First we need to know a little bit about you:
Date of Cancer Diagnosis
Name of Injured Person
Your Name. (If not the same)
Relationship to Injured Person
Age of Injured person
Daytime Phone Number
Night Phone Number
Address
Address
City
State
Zip
To help determine if you have a claim, we need to know some basic information about your history.
Do you know where you were exposed to Benzene? (Gasoline worker? Paint? Cleaning Solvents? Plastics?) If so please tell us where. (If you do not know this don't worry about it, we can talk with you and try to help you figure out where your were exposed.)
What kind of Leukemia do you have? Please check the one(s) you have if you know.	AML (Acute Myelogenous Leukemia) ALL (Acute Lymphocytic Leukemia) CLL (Chronic Lymphocytic Leukemia) CML (Chronic Myelogenous Leukemia) Non-Hodgkin's Lymphoma MyleoDysplastic Syndromes (MDS) Aplastic Anemia Multiple Myeloma
Please provide a description of your case and any other information you think we need to know.
Please provide your e-mail address. This is required so that we can respond to your inquiry. If you do not provide this then you may not receive a response, unless of course you have provided your phone number above.

We use your "Instant Answer" information solely to make a preliminary decision about whether you might have a claim and whether we might be able to help you. In reviewing your information we are NOT agreeing to represent you or take your case.