CanSAV Logo

1-877-922-6728 (9CANSAV)

info@cansav.ca

 

 

Support. Advocate. Facilitate. Educate.

THE CANADIAN SOCIETY FOR ASBESTOS VICTIMS

Compensation Information Form

There is a lot of information we are asking from you on this form. Don’t be overwhelmed. Just do the best you can. We can gather more information later as the process progresses.

If you would like to print a paper version of this form, fill it out and mail it to us, you can use the print version.

CONTACT PERSON
INJURED PERSON (IP) DETAILS





WORKSITES

Complete the following information for ALL employment positions the IP has held, to the best of his knowledge. This includes all employers IP worked for and each job site he worked at for each employer, including the city he worked in and trade at each job. Detail how IP may have been exposed to asbestos on each job. List employment even if IP not exposed to asbestos there.

EXPOSURE TO ASBESTOS
WORKER'S COMPENSATION BENEFITS
MEDICAL
RELEASE OF INFORMATION

CanSAV is not qualified to provide you with legal advice as to your potential entitlements to compensation in the US Tort System or against US Asbestos Trust Funds. We work closely with a number of law firms in the USA who specialise in claims for people with asbestos related diseases, and they operate on a contingency fee basis so that there are no fees and charges involved if you do not have a claim.

Release of Information

I hereby authorise CanSAV to contact me and provide me with details of law firms in the USA that may be able to assist me to investigate a claim for compensation. I understand that there is no obligation for me to pursue a claim with any law firm. In the event that I choose to hire a US law firm to represent me, I authorise CanSAV to provide any information in its possession which relates to my claim to that law firm.


captcha
Powered by BreezingForms

Copyright © 2017 CanSAV, Canadian Society for Asbestos Victims
Site by DarkHorse Web Design