Claim Form for Asbestos Diseases Click to Request a Call Back > Please complete and return this claims form. We will contact you shortly after receiving the form - usually within 24 hours. Name Daytime Telephone Evening Telephone Email Address . . . Age The date you were first aware of the condition Brief details of your employment history Where were you exposed to asbestos? Have you been diagnosed? If so, when was this? Claiming for Mesothelioma Asbestos Lung Cancer Asbestosis Pleural Thickening Pleural Plaques Asbestos Scarring Emphysema COPD Other Disease Contact by Phone Email Post We will look after your data with the utmost care. We will only use it to advise you. We will not send you any marketing information or share your data with any other companies.