9/11 Victim Compensation Fund Claim Application

Myself On behalf of a family member

First Name

Last Name

Phone Number

Address

City

State

Zip

Were you involved in 9/11 response or cleanup in the NYC Exposure Zone during the Exposure Time?

Yes No

Did you work, live, go to school, volunteer, or were otherwise present in the NYC Exposure Zone during the Exposure Time?

Yes No

Have you previously registered with the World Trade Center Health Program?

No Yes, registered only Yes, registered and they have linked one of my conditions to 9/11 exposure

Have you previously registered or filed a claim with the September 11th Victim Compensation Fund?

No Yes, registered only Yes, filed a claim which was not paid Yes, filed a claim which was paid

Were you diagnosed with any of the following conditions?

Acute Traumatic Injuries

Complex sprain

Eye injury

Fracture

Head trauma

Tendon tear

Other

Musculoskeletal Disorders

Carpal tunnel syndrome (CTS)

Low back pain

Other musculoskeletal disorders

Date of Diagnosis

Has any federal, state, or local government determined this condition is a result of 9/11-related exposure?

Yes No

Message

I expressly give consent to Environmental Litigation Group P.C. to contact me using email, SMS, phone calls, and pre-recorded messages at any phone number I provide, even if the number is a wireless number or on any federal or state do-not-call list. I understand calls may be placed using automated technology and that I am not required to submit this form for any reason.

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