Injured or Deceased Smoker's Information
Victim's First Name  
Victim's Last Name  
Date of Birth  
Date of Death (If Deceased)
Sex
Years Living in Florida To
Years Smoking Cigarettes To
Spouse's First Name
Spouse's Last Name
List any children born after 1965 (name and DOB)
Tobacco Related Disease
Disease
Diagnosis Date  
Doctor's Name
Doctor's Address
Record
Your Contact Information
Your First Name  
Your Last Name  
Relation to Injured  
Address Line 1  
Address Line 2
Email Address  
Telephone Number
City  
State
ZIP/Postal Code  
WE CANNOT SUBMIT YOUR CLAIM FOR THE GUARANTEED SUM UNTIL WE HAVE A SIGNED RETAINER AGREEMENT WITH WILNER BLOCK, P.A. AND FARAH & FARAH, P.A., ATTORNEYS AT LAW. THIS DOCUMENT WILL BE MAILED TO YOU SHORTLY AFTER YOU SUBMIT YOUR INTAKE.