Is the person who was exposed to Roundup you or a loved one? (If there are multiple family members exposed, please come back and complete the questions for each family member) *

Have you or a loved one been diagnosed with any of the following? *

Where was Roundup primarily used? *

How long did you or your loved one use Roundup? *

Are you currently being represented by a lawyer for a Roundup claim? *

First Name *

Last Name *

Phone *

Email *

City *

Current State

I understand by submitting this form that I am providing my consent to be contacted by National Injury Counsel LLC potentially using automated technology, at the number provided regarding my potential claim/their services. Consent is not required to use their services. Msg frequency varies, and message and data rates may apply. Reply HELP for help or STOP to unsubscribe. SMS Terms of Service. I understand and agree that by submitting this form I agree to the Privacy Policy and that this form does not create an attorney-client relationship and is not confidential or privileged and may be shared.

Captcha