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Do You Qualify
lpd-admin
2021-01-20T16:18:43-07:00
You may qualify for benefits. Please fill out the form below.
SOME ADDITIONAL INFORMATION ON HOW LONG THE PROCESS TAKES.
Are you filling this information out for yourself or for a family member/friend?
*
For Myself
For a Family Member
If Family Member/Friend please provide the following information.
Your Name
Your Phone Number
Former Worker Information
First Name
*
Last Name
*
Phone
*
Address
*
Street Address
Address Line 2
City
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District of Columbia
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Armed Forces Americas
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State
ZIP Code
What facillity did you work at?
*
When did you work there
*
To select multiple decades please hold (Shift/Control) and select decades.
1950-1960
1960-1970
1970-1980
1980-1990
1990-2000
2000-2010
2010-2019
Have you been diagnosed with cancer or a chronic illness such as COPD, kidney disease, lung disease, or asbestosis that may be linked to your work exposure?
*
NO
YES
If yes - What was your diagnosis and when were you diagnosed?
Do you experience symptoms like shortness of breath that may be linked to an undiagnosed condition?
*
(If yes, we can help you find a doctor to get tested for conditions that may qualify you for benefits.)
NO
YES
Where are you in your journey to applying for benefits?
*
Haven’t done anything, still learning about the program
I’m in the process of applying but could use some guidance
I’ve applied and been denied (We can help examine your case to see if you can reapply!)
I’ve applied and have received my white medical card (We can help you maximize your benefits!)
Phone
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