Asbestos Form

Thank you for choosing to complete our online questionnaire.

Please complete the questions in as much detail as you can. This information will enable us to provide you with preliminary advice as to whether or not you might have a claim for asbestos related disease, and if so, what your options are.

Once you have completed the form please check the details and pres the submit form.

This form will take approximately 10 minutes to complete.

If you would prefer to complete this form over the phone please call:

0870 143 0970

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Step 2

Asbestos Form

On what date were you advised that you have an asbestos-related illness? (dd/mm/yyyy) Month Year
What illness were you advised you were suffering from?
If you are suffering from pleural plaques, do you have any symptoms? If so, what are those symptoms?
Please name the consultant and hospital where the advice was given.
Please list the employers where you were exposed to asbestos.
In relation to each employer at which you were exposed to asbestos, please list as much of the following as you can:
- the name of the employer
- the address of the employer
- the dates when you worked for the employer
- your job title
- how you were exposed to asbestos and approximately how frequently you were exposed during your employment
- whether the employer is still in business

Personal details

Title
First Name
Surname
Address
Post Code
Contact telephone number
Email address
Date of Birth (dd/mm/yyyy) Month Year
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Asbestos Form

If you would prefer to complete this form over the phone please call:

0870 143 0970

Asbestos Form

Personal details

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