Contact Us

Submit Questionnaire

Our firm is very interested in hearing from you. We will be happy to provide you with a free, no obligation consultation. We will assess your situation to find out if you have a claim for mesothelioma cancer as a result of negligent exposure to asbestos.

Please complete the questionnaire below as best as you can. We will respond to you as soon as possible. All of the information you provide us will be kept in the strictest of confidence and will not be provided to anyone outside the firm of Michael B. Serling, P.C. and their co-counsel.

If you prefer, you can call us on our toll free number (800) 995-6991, or simply e-mail us by clicking on the e-mail button at the right.

FIRST NAME OF
CONTACT PERSON
LAST NAME OF
CONTACT PERSON
PHONE  NO. OF CONTACT PERSON
ADDRESS OF
CONTACT PERSON
CITY
STATE

ZIP
EMAIL ADDRESS
FIRST NAME OF ASBESTOS
 EXPOSURE VICTIM
LAST NAME OF ASBESTOS
 EXPOSURE VICTIM
PHONE NUMBER OF ASBESTOS VICTIM [IF DIFFERENT FROM CONTACT]
ADDRESS OF ASBESTOS VICTIM [IF DIFFERENT FROM CONTACT]
CITY
STATE

ZIP
BIRTH DATE OF VICTIM
DATE OF DEATH OF VICTIM
NAME OF ASBESTOSIS DISEASE
DATE OF DIAGNOSIS
NAME OF DIAGNOSING FACILITY
OCCUPATION OF VICTIM
FIRST YEAR IN THAT OCCUPATION
YEAR OF RETIREMENT

Thank you for filling out the information above.  Please Click SEND to send this data immediately so that we may be able to begin assessing your situation.

  

Please Wait for the form to process after clicking SEND.  A  confirmation page will appear once the form is processed.