Defective Earplug Injury Claims

Additional Court Ordered Info Required for Your Defective Earplug Injury Claim

This is the COURT-ORDERED form that must be SIGNED and VERIFIED as truthful by you. We have made it as short, easy to use, and accessible as possible for your convenience. You must complete all of the required fields and wait for your entries to appear in the OFFICIAL COURT-ORDERED document that you will then digitally sign at the end.

Failure to complete this form means your case will be dismissed, and you will NOT be able to receive compensation for your 3M Earplug Injury.

1 PERSONAL DETAILS

* = required

Claimant's first name * Example: John

Claimant's last name * Example: Smith

Claimant's e-mail * Example: yourname@someplace.com

Claimant's gender *

Claimant's date of birth * Must be in Format: 06/18/1971

Claimant's social security number Enter numbers only, we'll format it for you (needed to order your medical records)

Claimant's current state of residence * This is the state you live in

Claimant's number of years at residence * Example: 12