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Silicosis (lung cancer)

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Defendant:
(who caused the harm?)

Silicosis (lung cancer, tuberculosis)

*Describe your complaint:
(briefly describe the damages you have suffered)

When were you exposed?

What company did you work for during this time?

Lung disease?

Yes No

Tuberculosis?

Yes No

If death occured, what is your relationship:

*First name:

*Last name:

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