Defective Earplug Injury Claims

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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