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Your Info
First Name:
*
Last Name:
*
Firm Name:
*
Email:
*
Email 2 (optional):
Email 3 (optional):
Claimant
First name:
*
Last Name:
*
Phone:
*
Email:
Case Type
*
3M Earplugs
Auto Accident
Birth Injury
Camp Lejeune
CPAP Machine
Exactech
Elmiron
Firefighting Foam
Hair Relaxer
Hernia Mesh
Hurricane Insurance
Infant Formula NEC
Invokana
IVC Filter
Lung Cancer
Mesothelioma
Paraquat
Roundup
Steven Johnson
Talcum Powder
Case ID:
*
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Replacement Information
Reason for Replacement (must be within 14 days of delivery):
*
Already Represented
Did not meet predetermined criteria
Previously retained firm(s)
*
Date previous firm(s) retained
*
+
Details: Please review the criteria information provided during your onboarding process and provide the Exact Criteria that was not met for this claimant
*
Please be informed that upon acceptance of a replacement request our office will automatically generate a close letter and forward it to the claimant if our firm is listed on the retainer agreement. In all other instances, it is the requesting firms responsibility to provide the claimant and all offices a close letter that includes all associated firms.