MT-01 AFFF Firefighter Foam | Maas Attorney Intake

1Center information

Center Code

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Agent Name

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TF Link (TrustedForm certificate URL)

Paste the TrustedForm certificate link (https://cert.trustedform.com/…)

Call type

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Lead source / publisher (optional)

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2Qualification

Are you currently represented by an attorney for this matter?

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DQ: Represented by attorney

Have you spoken to or signed with another law firm about this before?

Required

Have you already settled or signed a release for this injury?

Required

DQ: Already settled / released

Have you been convicted of a felony?

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Have you filed for bankruptcy since the injury / diagnosis?

Required

3Client information

Client First Name

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Middle Name

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Client Last Name

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Suffix

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Gender

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Birthdate

Valid birthdate required (18+)

Marital status

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Client Street (Primary)

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Apt / Unit

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Client City (Primary)

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Client State (Primary)

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Client Zip Code (Primary)

5-digit ZIP

Client Phone (Primary) (10 Digit Number Only - No Hyphens or Parenthesis)

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Alternate Phone

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Client Email (Primary)

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Best time to call

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Preferred language

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4Injured person

Is the client the injured person?

Required

Injured person's full name

Required

Injured person's date of birth

Required

Client's relationship to the injured person

Required

Date of death

Required

Cause of death (per death certificate)

Required

Is the client the executor / estate representative?

Required

5Medical & insurance

Main treating doctor / hospital (name & city)

Required

Primary care doctor (name & city)

Required

Pharmacy used (name & city)

Required

6MT-01 · AFFF Firefighter Foam questions

How were you exposed to AFFF firefighting foam?

Required

DQ: No AFFF exposure

Base, fire department or site of exposure

Required

Years of exposure (e.g. 1998 – 2012)

Required

What were you diagnosed with?

Required

DQ: No qualifying diagnosis

Other diagnosis

Required

Date of diagnosis

Required

Is the injured person living or deceased?

Required

Can medical records confirm the diagnosis?

Required

7Case summary & documents

Case summary – what happened, in the client's own words

Required

Documents the client has or can get

Select at least one

Upload documents (optional – attach anything the client has already sent)📎 Click to attach documents or drag files herePDF, photos (JPG / PNG / HEIC), Word · up to 10 files · 10 MB each

Check the files: max 10 files, 10 MB each

Agent notes (internal)

Required

MT-01 AFFF Firefighter Foam Intake

1Center information

2Qualification

3Client information

4Injured person

5Medical & insurance

6MT-01 · AFFF Firefighter Foam questions

7Case summary & documents

Submitted