If you or a family member has been injured by Asbestos you may be entitled to compensation. Please complete this questionnaire to the best of your ability with as much detail as possible. If you are unsure of the dates, names, addresses, etc., submit the questionnaire and we will obtain any other necessary information at a later date. In the comments section, you may indicate any other pertinent information or requests. If you would like to contact Napoli Bern, LLP for reasons other than a Asbestos related personal injury claim, please email info@nblawfirm.com or call 1-888-LAW-IN-NY. There is no charge for this evaluation Your Name: Street Address: City: State: Zip: E-mail (required): Phone Number: Work Number: Date of Birth: Asbestos Exposure Information: Have you received a positive diagnosis for asbestos-related disease?   YesNo Comments/Questions? Important Legal Disclaimers: Yes No - I agree that this matter may be referred to an attorney in my area who may contact me. Yes - I understand that I am not forming a formal attorney/client relationship. This Asbestos Questionnaire is Confidential By Clicking the appropriate box below, I agree to: