Asbestos Questionnaire

Please enter your membership number. We will then ask you to verify that your details are correct.
If you don't have your membership number to hand, please call a member of our team on 0800 709 007.

Please provide your Unite password

Not a member of Unite? Click here to Join Unite today.
Not logged in before? Click here to activate your account.

Title

First name

Surname

Email address

Address

Post code

Phone number

Unite region

Branch

Are the above details correct?

Thank you for confirming the details above are correct.

Please login to MyUnite to update your contact details.
Once your details have been updated please start completing this form again.

Return home Reset form

Asbestos exposure

Have you been exposed to asbestos?

Yes No

Brief description of how you were exposed to asbestos:

Employer (name and address)
Site location where exposure occured (address)

Dates of employment

Start:

End:

Brief description of how you were exposed to asbestos

Please use +/- buttons to add or remove additional employer details relating to your exposure

Medical diagnosis

Have you ever been told that you may be suffering from any asbestos related disease?

Yes No

Have you been told which of the following you are suffering from? Please select all that apply

Mesothelioma

Pleural Plaques

Pleural Thickening

Asbestosis

Lung Cancer

When were you diagnosed?

DWP claims

Have you ever applied to the DWP for benefit for asbestos related disease?

Yes No

When did you claim?

Previous legal claims

Have you ever previously obtained legal advice in connection with your asbestos exposure?

Yes No

Please give the name and address of the solicitors:

Confirmations

Confirmation of statement

I confirm the content of this statement is true

Consent of use

I consent to this information being used by Unite Legal Services for the purpose of assisting personal injury claims

Unite Legal Services Asbestos Questionnaire

Asbestos exposure

Medical diagnosis

DWP claims

Previous legal claims

Confirmations

Head office

Unite Legal Services

Services