Form

1201 Pacific Avenue, Suite 600

Tacoma, WA 98402-4384

First Name*

Middle Name

Last Name*

Street address*

City*

State/Region*

Postal code*

DOB*

Month/Day/Year

Email*

Phone number*

Initial Qualifying Criteria

Not checked means no checked means yes

Client is not living outside the U.S.*

Not checked means no checked means yes

Client is not currently represented by another firm regarding this case.*

Not checked means no checked means yes

Client used, mixed, applied, or was exposed to a Paraquat-containing product (Trade names: Paraquat, Ortho-Paraquat, Parazone, Para Shot, Gramoxone, Firestorm, Helmquat, Parazone, Cyclone).*

Not checked means no checked means yes

Client used, mixed, applied, or was exposed to a Paraquat-containing product after 1966.*

Not checked means no checked means yes

Client did not use, mix, apply, or experience exposure to a Paraquat-containing product in a residential setting only.*

Not checked means no checked means yes

If client is deceased, and the use/exposure occurred only in Florida, Georgia, Idaho, New Jersey, New York, Pennsylvania, Texas, Virginia, Wyoming, the date of death was no longer than two years ago.

Not checked means no checked means yes

If client is deceased, and use/exposure occurred only in Arkansas, Michigan, Missouri, New Mexico, the date of death was no longer than three years ago.

Qualifying Criteria For Parkinson’s Claim

Not checked means no checked means yes

Client either has a diagnosis of Parkinson’s Disease or suspects that one of the following symptoms is possibly the result of Parkinson’s Disease: Hand tremors, trembling, extreme stiffness, difficulty speaking, difficulty walking (slow gait, shuffling), reduced facial expression, blank state, drooling, unusually small handwriting, amnesia or confusion in evening hours, hallucinations (seeing, hearing, or experiencing things others aren’t), delusions (believing things that are not true).*

Not checked means no checked means yes

Diagnosis of Parkinson’s Disease/relevant symptoms began after use, mixture, application, or exposure to Paraquat.*

Qualifying Criteria For Kidney Disease Claim

Client is either on dialysis or has had a kidney transplant*

Not checked means no checked means yes

Kidney transplant or placement on dialysis occurred after use, mixture, application, or exposure to Paraquat.*

Not checked means no checked means yes

Client is does not have diabetic retinopathy

Not checked means no checked means yes

Does client have proof of Paraquat exposure?

How old was client when diagnosed with [Parkinson’s Disease/Kidney disease]?*

Not checked means no checked means yes

Does client have family history of Parkinson’s Disease?*

What is client’s current medical condition?*

What medical treatment has client received related to [Parkinson’s Disease/Kidney Disease, as appropriate]*

How did client learn that exposure to Paraquat may have caused [Parkinson’s Disease/Kidney Disease]?*