https://storage.googleapis.com/teampass/0023/7374t.html#2476103YU6608136Xc367522450dW11393Pv24MZr167985iO

Last Checked: Dec 10, 2022, 23:49 EST

IP Address: 142.251.32.48
ASN #: AS15169 GOOGLE, US
Location: Unknown, Unknown, Unknown
URL Reputation:
  • Unknown This URL is not identified as malicious in the PhishTank Database.
  • Unknown PhishCheck thinks this URL is likely not a phish.
  • Unknown OpenPhish: URL not in feed.

Other submissions on 142.251.32.48:

  • https://storage.googleapis.com/rdcoffer/offertrc.html#lnjjmi2gyufh63c2dbfdf2bbb.67l604fb54c88b19

  • https://storage.googleapis.com/mjgzev42153zef/ouihcfhdv.html#ZE0X24NAHZDB.ZE0X24NAHZDB?ffCqrQcc9NW6cyfmncdc8WcBc546xfKJmcbbb4G

Other submissions on googleapis.com:

  • https://storage.googleapis.com/akesel/akesel.html#/rd/c7011Ntyan614431YTtY43022aJm1578bWFa20

  • https://storage.googleapis.com/bionat/xbitco1.html

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  • https://fonts.googleapis.com/css?family=Cabin:400,700

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  • https://storage.googleapis.com/instahard00021/instahard4445555111.html

  • http://storage.googleapis.com/descargafactura/Descargar.htm

  • https://storage.googleapis.com/checkthisbuckets/dsdgrf%20vder%20rbvc.html#1824222We2822223SM443008610ca13278gU24zgr110761Uq

  • https://storage.googleapis.com/issosales/hrefly.html#?Z289MSZzMT0xMDkyMjcwJnMyPTMwNDY4MjM5JnMzPUdMQg==

  • https://storage.googleapis.com/issosales/hrefly.html#?Z289MSZzMT0xMDkyMjcwJnMyPTMwNDY4MjM5JnMzPUdMQg==

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                <h1 class="cta-1   mt-lg-0 text-center " style="margin-bottom: 0; color: #000000;">
                    <span>
                        <strong>Camp Lejeune Water Contamination Lawsuits are now being filed!</strong>
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                </h1>
                <h1 class="cta-2   mt-lg-0 text-center " style="line-height:0.8;">
                    <span style="color:#cc0000 !important; font-size:35px;text-shadow: -1px 0 white, 0 1px white, 1px 0 white, 0 -1px white;">Camp Lejeune Justice Act passes U.S. Senate as part of PACT Act as of August 10th, 2022*</span>
                </h1>

                <div class=" stage-list mt-lg-5" style="padding-left:0 !important;">
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                            <h2 class="h3 text-left p-1 pt-0 ml-4 " style=" color:#333;">
                                <strong>Signs &amp; Symptoms</strong>
                                <hr class="d-block mx-auto">
                            </h2>
                        </li>
                        <li class="ml-2" style="display:flex">
                            <i class="fa fa-check d-inline fa-2x" aria-hidden="true"></i>
                            <h3 class="h5 d-inline">Bladder Cancer</h3>
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                        <li class="ml-2" style="display:flex">
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                            <h3 class="h5 d-inline">Cardiac Birth Defects</h3>
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                        <li class="ml-2" style="display:flex">
                            <i class="fa fa-check d-inline  fa-2x" aria-hidden="true"></i>
                            <h3 class="h5 d-inline">Female Infertility</h3>
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                        <li class="ml-2" style="display:flex">
                            <i class="fa fa-check d-inline  fa-2x" aria-hidden="true"></i>
                            <h3 class="h5 d-inline">Hepatic Steatosis</h3>
                        </li>
                        <li class="ml-2" style="display:flex">
                            <i class="fa fa-check d-inline  fa-2x" aria-hidden="true"></i>
                            <h3 class="h5 d-inline">Miscarriage</h3>
                        </li>
                        <li class="ml-2" style="display:flex">
                            <i class="fa fa-check d-inline  fa-2x" aria-hidden="true"></i>
                            <h3 class="h5 d-inline">Neurobehavioral Effects</h3>
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                        <li class="ml-2" style="display:flex">
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                            <h3 class="h5 d-inline">Other Cancers</h3>
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                        <li class="ml-2" style="display:flex">
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                <h4 class="h3 text-center p-0 pb-2 pt-0 m-0 d-md-block d-lg-none " style=" color:#333;">
                    <strong>Camp Lejeune Water Contamination Lawsuits are now being filed!</strong>
                </h4>
                <span style="font-size:1.25rem;line-height:1;color:#cc0000;">
                    Camp Lejeune Justice Act passes U.S. Senate as part of PACT Act as of August 10th, 2022*
                </span>

                <div class="well form p-3 mt-4 shadow  " style=" ">
                    <h4 class="text-center  bubble text-white" style=" margin-bottom:20px; padding-left:0; padding-right:0 " id="form-top">
                        <span style="color:yellow;">Time is Limited<br></span>
                        FILL OUT THE FORM BELOW
                        <br>
                        <strong class="" id="form-top-2nd-line">TO GET YOUR FREE CLAIM REVIEW</strong>
                        <br>
                        <span class="" style="font-size: 19px; !important
; font-weight: normal; color:ghostwhite!important;"> 
                            You may be entitled to  
                            <span style=" text-decoration: underline; white-space:nowrap;">
                                <strong class="">financial compensation!</strong>
                            </span>
                        </span>
                    </h4>
                    <span class="hidden-sm hidden-xs d-none" style="text-align:center; font-size:15px; color:#666; width:90%; display:block; margin:0 auto 10px auto; position:relative; top:-10px; "> 
                        You may be entitled to 
                        <span style="text-decoration: underline;">financial compensation!</span>
                    </span>

                    <form id="main_form" name="main_form" method="post" class="form-horizontal" action="/camp-lejeune1/es/submit.php">
                        <div class="container" style="background: white">
                            <div class="row">
                                <div id="myProgress" style="width:100%">
                                    <div id="myProgressBar">0%</div>
                                </div>
                                <div class="col-md-12" id="welcome_title" style="padding: 10px;">
                                    <p>
                                        <strong>Hi there. I can help you see if you qualify for a
                                            Camp Lejeune claim!
                                        </strong>
                                        <br>
                                        The information you provide me is confidential and will only be shared with the
                                        lawyers I work with.
                                    </p>
                                </div>
                            </div>
                            <div class="row" style="padding: 10px;">
                                <div class="col-md-12" style="text-align: left">
                                    <fieldset class="pb-3 pb-md-0 text-center" id="div_relationship">
                                        <div class="form-check" id="relationship_form_check">
                                            <span><strong>Is the affected individual you or a loved one?</strong></span><br>
                                            <input type="radio" class="btn-check" name="relationship" id="relationship_myself" autocomplete="off" value="myself">
                                            <label class="btn btn-primary myselfLabel" for="relationship_myself" style="width:100%;border:solid grey 1px;">Myself</label><br>
                                            <input type="radio" class="btn-check" name="relationship" id="relationship_loved_one" autocomplete="off" value="loved_one">
                                            <label class="btn btn-primary lovedOneLabel" for="relationship_loved_one" style="width:100%;border:solid grey 1px;">Loved One</label>
                                        </div>
                                    </fieldset>
                                    <fieldset class="pb-3 pb-md-0 text-center" id="div_served">
                                        <div class="form-check">
                                            <span>
                                                <strong>Did you or a loved one Serve, Live or Work at Marine Corps Base Camp Lejeune between Aug. 1953 and Dec. 1987?</strong>
                                            </span>
                                            <br>
                                            <input type="radio" class="btn-check" id="served_yes" name="served" autocomplete="off" value="1">
                                            <label class="btn btn-primary" for="served_yes" style="width:100%;border:solid grey 1px;">Yes</label><br>
                                            <input type="radio" class="btn-check" id="served_no" name="served" autocomplete="off" value="0">
                                            <label class="btn btn-primary" for="served_no" style="width:100%;border:solid grey 1px;">No</label>
                                        </div>
                                    </fieldset>
                                    <fieldset class="pb-3 pb-md-0 text-center" id="div_diagnosis">
                                        <div class="row">
                                            <div class="col-md-12" style="background-color:#FFDB58;border-radius:4px;">
                                                <span>
                                                    <i class="fa fa-lightbulb"></i>
                                                    <strong>**Diagnosis is needed to determine if you have a valid case against Camp Lejeune</strong>
                                                </span>
                                            </div>
                                            <div class="col-md-12">
                                                <span>
                                                    <strong>Have you or a loved one been diagnosed with:</strong>
                                                </span>
                                                <br>
                                                                                                <select name="diagnosis" id="diagnosis" class="form-control-lg" style="width:75% !important;margin-left:auto;margin-right:auto">
                                                    <option value="" selected="selected" style="">[ Select ]
                                                    </option>
                                                                                                            <option value="acute_lymphoblastic_leukemia">
                                                            Acute Lymphoblastic Leukemia (ALL)                                                        </option>
                                                                                                            <option value="acute_myeloid_leukemia">
                                                            Acute Myeloid Leukemia (AML)                                                        </option>
                                                                                                            <option value="amyotrophic_lateral_sclerosis">
                                                            Amyotrophic Lateral Sclerosis (ALS)                                                        </option>
                                                                                                            <option value="anal_cancer">
                                                            Anal Cancer                                                        </option>
                                                                                                            <option value="appendix_cancer">
                                                            Appendix cancer                                                        </option>
                                                                                                            <option value="aplastic_anemia">
                                                            Aplastic Anemia                                                        </option>
                                                                                                            <option value="atrial_septal_defect">
                                                            Atrial Septal Defect                                                        </option>
                                                                                                            <option value="bile_duct_cancer">
                                                            Bile duct cancer                                                        </option>
                                                                                                            <option value="birth_defects_malformation">
                                                            Birth defects/malformation                                                        </option>
                                                                                                            <option value="bladder_cancer">
                                                            Bladder Cancer                                                        </option>
                                                                                                            <option value="bone_cancer">
                                                            Bone Cancer                                                        </option>
                                                                                                            <option value="brain_cns">
                                                            Brain CNS Cancers                                                        </option>
                                                                                                            <option value="breast_cancer">
                                                            Breast Cancer                                                        </option>
                                                                                                            <option value="cardiac_birth_defects">
                                                            Born with Cardiac Birth Defects                                                        </option>
                                                                                                            <option value="cervical_cancer">
                                                            Cervical Cancer                                                        </option>
                                                                                                            <option value="central_nervous_system_cancer">
                                                            Central nervous system cancer                                                        </option>
                                                                                                            <option value="childhood_cancer">
                                                            Childhood Cancers                                                        </option>
                                                                                                            <option value="chronic_lymphocytic_leukemia_cll">
                                                            Chronic Lymphocytic Leukemia (CLL)                                                        </option>
                                                                                                            <option value="chronic_myelogenous_leukemia_cml">
                                                            Chronic Myelogenous Leukemia (CML)                                                        </option>
                                                                                                            <option value="colorectal_cancer">
                                                            Colorectal cancer                                                        </option>
                                                                                                            <option value="dental_issues">
                                                            Dental Issues/Tooth                                                        </option>
                                                                                                            <option value="esophageal_cancer">
                                                            Esophageal Cancer                                                        </option>
                                                                                                            <option value="extragonadal_germ_cell_cancer">
                                                            Extragonadal Germ Cell cancer                                                        </option>
                                                                                                            <option value="eye_cancer">
                                                            Eye Cancer                                                        </option>
                                                                                                            <option value="fallopian_tube_cancer">
                                                            Fallopian Tube Cancer                                                        </option>
                                                                                                            <option value="female_infertility">
                                                            Female Infertility                                                        </option>
                                                                                                            <option value="fetal_death">
                                                            Fetal Death                                                        </option>
                                                                                                            <option value="gallbladder_cancer">
                                                            Gallbladder cancer                                                        </option>
                                                                                                            <option value="gastrointestinal_cancer">
                                                            Gastrointestinal Cancer                                                        </option>
                                                                                                            <option value="germ_cell_cancer">
                                                            Germ Cell Cancer                                                        </option>
                                                                                                            <option value="gestational_trophoblastic_disease">
                                                            Gestational Trophoblastic disease                                                        </option>
                                                                                                            <option value="hairy_cell_leukemia">
                                                            Hairy Cell Leukemia                                                        </option>
                                                                                                            <option value="head_and_neck_cancer">
                                                            Head and Neck cancer                                                        </option>
                                                                                                            <option value="heart_attack">
                                                            Heart Attack                                                        </option>
                                                                                                            <option value="hepatic_steatosis">
                                                            Hepatic Steatosis                                                        </option>
                                                                                                            <option value="hodgkins_lymphoma">
                                                            Hodgkins Lymphoma                                                        </option>
                                                                                                            <option value="infertility">
                                                            Infertility                                                        </option>
                                                                                                            <option value="intestinal_cancer">
                                                            Intestinal cancer                                                        </option>
                                                                                                            <option value="kidney_cancer">
                                                            Kidney Cancer                                                        </option>
                                                                                                            <option value="kidney_disease">
                                                            Kidney Disease                                                        </option>
                                                                                                            <option value="laryngeal_cancer">
                                                            Laryngeal Cancer                                                        </option>
                                                                                                            <option value="leukemia">
                                                            Leukemia                                                        </option>
                                                                                                            <option value="liver_cancer">
                                                            Liver Cancer                                                        </option>
                                                                                                            <option value="lung_cancer">
                                                            Lung Cancer                                                        </option>
                                                                                                            <option value="metastatic_cancer">
                                                            Metastatic cancer                                                        </option>
                                                                                                            <option value="miscarriage">
                                                            Miscarriage                                                        </option>
                                                                                                            <option value="multiple_myeloma">
                                                            Multiple Myeloma                                                        </option>
                                                                                                            <option value="multiple_sclerosis">
                                                            Multiple Sclerosis (MS)                                                        </option>
                                                                                                            <option value="mycosis_fungoides">
                                                            Mycosis Fungoides                                                        </option>
                                                                                                            <option value="myelodysplastic_syndromes">
                                                            Myelodysplastic Syndromes (MDS)                                                        </option>
                                                                                                            <option value="neurobehavioral_effects">
                                                            Neurobehavioral Effects                                                        </option>
                                                                                                            <option value="nhl">
                                                            Non-Hodgkin's Lymphoma (NHL)                                                        </option>
                                                                                                            <option value="ovarian_cancer">
                                                            Ovarian cancer                                                        </option>
                                                                                                            <option value="pancreatic_cancer">
                                                            Pancreatic Cancer                                                        </option>
                                                                                                            <option value="parkinsons_disease">
                                                            Parkinson's Disease                                                        </option>
                                                                                                            <option value="patent_ductus_arteriosus">
                                                            Patent Ductus Arteriosus                                                        </option>
                                                                                                            <option value="primary_cns_lymphoma">
                                                            Primary CNS Lymphoma                                                        </option>
                                                                                                            <option value="prostate_cancer">
                                                            Prostate Cancer                                                        </option>
                                                                                                            <option value="rectal_cancer">
                                                            Rectal Cancer                                                        </option>
                                                                                                            <option value="renal_toxicity">
                                                            Renal Toxicity                                                        </option>
                                                                                                            <option value="scleroderma">
                                                            Scleroderma                                                        </option>
                                                                                                            <option value="sinus_cancer">
                                                            Sinus cancer                                                        </option>
                                                                                                            <option value="soft_tissue_sarcoma">
                                                            Soft tissue sarcoma                                                        </option>
                                                                                                            <option value="spinal_cancer">
                                                            Spinal cancer                                                        </option>
                                                                                                            <option value="stomach_cancer">
                                                            Stomach Cancer                                                        </option>
                                                                                                            <option value="testicular_cancer">
                                                            Testicular Cancer                                                        </option>
                                                                                                            <option value="tetralogy_of_fallot">
                                                            Tetralogy of Fallot                                                        </option>
                                                                                                            <option value="thyroid_cancer">
                                                            Thyroid Cancer                                                        </option>
                                                                                                            <option value="transposition_of_great_arteries">
                                                            Transposition of the Great Arteries                                                        </option>
                                                                                                            <option value="uterine_cancer">
                                                            Uterine Cancer                                                        </option>
                                                                                                            <option value="vascular_tumors">
                                                            Vascular Tumors                                                        </option>
                                                                                                            <option value="ventricular_septal_defect">
                                                            Ventricular Septal Defect                                                        </option>
                                                                                                            <option value="other">
                                                            Other                                                        </option>
                                                                                                            <option value="no_diagnosis">
                                                            None                                                        </option>
                                                                                                    </select>
                                            </div>
                                        </div>
                                    </fieldset>

                                    <fieldset class="pb-3 pb-md-0 text-center" id="div_mother_pregnant">
                                        <div class="form-check">
                                            <span><strong>Did your mother reside at CLJ when you were born, or was your mother pregnant with you when she resided at Camp Lejeune?</strong></span><br>
                                            <input type="radio" class="btn-check" id="mother_pregnant_yes" name="mother_pregnant" autocomplete="off" value="1">
                                            <label class="btn btn-primary" for="mother_pregnant_yes" style="width:100%;border:solid grey 1px;">Yes</label><br>
                                            <input type="radio" class="btn-check" id="mother_pregnant_no" name="mother_pregnant" autocomplete="off" value="0">
                                            <label class="btn btn-primary" for="mother_pregnant_no" style="width:100%;border:solid grey 1px;">No</label>
                                        </div>
                                    </fieldset>

                                    <fieldset class="pb-3 pb-md-0 text-center" id="div_have_attorney">
                                        <div class="form-check">
                                            <span><strong>Do you currently have another law firm representing you on this claim?</strong></span><br>
                                            <input type="radio" class="btn-check" id="have_attorney_yes" name="have_attorney" autocomplete="off" value="1">
                                            <label class="btn btn-primary" for="have_attorney_yes" style="width:100%;border:solid grey 1px;">Yes</label><br>
                                            <input type="radio" class="btn-check" id="have_attorney_no" name="have_attorney" autocomplete="off" value="0">
                                            <label class="btn btn-primary" for="have_attorney_no" style="width:100%;border:solid grey 1px;">No</label>
                                        </div>
                                    </fieldset>

                                    <fieldset class="pb-1 pb-md-0 text-center" id="gender">
                                        <div class="row">
                                            <div class="col-md-12">
                                                <div class="form-check">
                                                    <span>
                                                        <strong>Please select the gender of the injured individual:</strong>
                                                    </span>
                                                    <br>

                                                    <input type="radio" class="btn-check gender" name="gender" id="gender_female" autocomplete="off" value="female">
                                                    <label class="btn btn-primary" for="gender_female" style="width:100%;border:solid grey 1px;">
                                                        Female
                                                    </label>
                                                    <br>

                                                    <input type="radio" class="btn-check gender" name="gender" id="gender_male" autocomplete="off" value="male">
                                                    <label class="btn btn-primary" for="gender_male" style="width:100%;border:solid grey 1px;">
                                                        Male
                                                    </label>
                                                </div>
                                            </div>
                                        </div>
                                    </fieldset>

                                    <fieldset class="pb-1 pb-md-0 text-center" id="contact_info">
                                        <span><strong>Your Claim Results Are Ready !</strong></span><br><br>
                                        <span>Receive your claim results by submitting your information so we can connect you with a lawyer.</span>
                                        <div class="row input-group mb-0">
                                            <div class=" col-md-12">
                                                <input vtype="not_empty" type="text" class="form-control form-control-lg " id="edit_firstname" name="edit_firstname" placeholder="First Name" value="" minlength="3">
                                            </div>
                                            <div class=" col-md-12">
                                                <input vtype="not_empty" type="text" class="form-control form-control-lg" id="edit_lastname" name="edit_lastname" placeholder="Last Name" value="" minlength="3">
                                            </div>
                                        </div>
                                        <div class="row input-group mb-0  ">
                                            <div class=" col-md-12">
                                                <input type="email" id="edit_email" name="edit_email" placeholder="Email" pattern="^([\w\.\-]+)@([\w\-]+)((\.(\w){2,3})+)$" data-required="true" class=" form-control form-control-lg  " value="">
                                            </div>
                                            <div class=" col-md-12">
                                                <input class="form-control form-control-lg" data-val="true" pattern="^[\(]?[2-9]{1}[0-9]{2}[\)]?[.\- ]?[2-9]{1}[0-9]{2}[.\- ]?[0-9]{4}$" data-val-regex="Please enter a valid number" data-val-required="Phone is required." id="edit_phone" name="edit_phone" placeholder="Phone" type="tel" value="" data-required="true">
                                            </div>
                                        </div>
                                        <div class="row input-group mb-0">
                                            <div class=" col-md-12">
                                                <input vtype="zip" type="text" class="form-control form-control-lg" id="edit_zip" name="edit_zip" placeholder="Zip" maxlength="5" minlength="5" value="">
                                            </div>
                                        </div>
                                    </fieldset>

                                    <fieldset class="pb-1 pb-md-0" id="div_may_have_claim">
                                        <div class="card mb-3 text-center">
                                            <div class="card-header bg-success text-white">You May Have A Claim!</div>
                                            <div class="card-body">
                                                <p class="card-text">Based on the
                                                    information you provided
                                                    it appears you may have
                                                    a claim.
                                                    <br>We just have a
                                                    few more questions
                                                    before we connect
                                                    you with one of our
                                                    lawyers.
                                                </p>
                                            </div>
                                        </div>
                                        <div class="row deceased_row text-center">
                                            <fieldset class="pb-3 pb-md-0" id="div_deceased">
                                                <div class="form-check">
                                                    <span><strong>Is the injured party deceased?</strong></span><br>
                                                    <input type="radio" class="btn-check" id="deceased_yes" name="deceased" autocomplete="off" value="1">
                                                    <label class="btn btn-primary" for="deceased_yes" style="width:100%;border:solid grey 1px;">Yes</label><br>
                                                    <input type="radio" class="btn-check" id="deceased_no" name="deceased" autocomplete="off" value="0">
                                                    <label class="btn btn-primary" for="deceased_no" style="width:100%;border:solid grey 1px;">No</label>
                                                    <input type="radio" class="btn-check" id="deceased_na" name="deceased" autocomplete="off" value="N/A" hidden="">
                                                </div>
                                            </fieldset>
                                        </div>
                                    </fieldset>
                                </div>

                                <fieldset class="pb-1 pb-md-0 text-center" id="div_deceased_date">
                                    <div class="row">
                                        <div class="col-md-12">
                                            <span><strong>When did your loved one pass away?</strong></span><br>
                                            <div class="row">
                                                <div class="col-md-4">
                                                    <select id="edit_deceased_month" name="edit_deceased_month" class="form-select form-dob-select" vtype="not_empty" style="width: 100% !important;">
                                                        <option value="" selected="selected">Month</option>
                                                        <option value="01"> Jan</option>
                                                        <option value="02"> Feb</option>
                                                        <option value="03"> Mar</option>
                                                        <option value="04"> Apr</option>
                                                        <option value="05"> May</option>
                                                        <option value="06"> Jun</option>
                                                        <option value="07"> Jul</option>
                                                        <option value="08"> Aug</option>
                                                        <option value="09"> Sep</option>
                                                        <option value="10"> Oct</option>
                                                        <option value="11"> Nov</option>
                                                        <option value="12"> Dec</option>
                                                    </select>

                                                </div>

                                                <div class="col-md-4">
                                                    <select id="edit_deceased_day" name="edit_deceased_day" class="form-select form-dob-select" vtype="not_empty" style="width: 100% !important;">
                                                        <option value="" selected="selected">Day</option>
                                                        <option value="01"> 1</option><option value="02"> 2</option><option value="03"> 3</option><option value="04"> 4</option><option value="05"> 5</option><option value="06"> 6</option><option value="07"> 7</option><option value="08"> 8</option><option value="09"> 9</option><option value="10"> 10</option><option value="11"> 11</option><option value="12"> 12</option><option value="13"> 13</option><option value="14"> 14</option><option value="15"> 15</option><option value="16"> 16</option><option value="17"> 17</option><option value="18"> 18</option><option value="19"> 19</option><option value="20"> 20</option><option value="21"> 21</option><option value="22"> 22</option><option value="23"> 23</option><option value="24"> 24</option><option value="25"> 25</option><option value="26"> 26</option><option value="27"> 27</option><option value="28"> 28</option><option value="29"> 29</option><option value="30"> 30</option><option value="31"> 31</option>                                                    </select>
                                                </div>

                                                <div class="col-md-4">
                                                    <select id="edit_deceased_year" name="edit_deceased_year" class="form-select form-dob-select" vtype="not_empty" style="width: 100% !important;">
                                                        <option value="">Year</option>
                                                        <option value="2022"> 2022</option><option value="2021"> 2021</option><option value="2020"> 2020</option><option value="2019"> 2019</option><option value="2018"> 2018</option><option value="2017"> 2017</option><option value="2016"> 2016</option><option value="2015"> 2015</option><option value="2014"> 2014</option><option value="2013"> 2013</option><option value="2012"> 2012</option><option value="2011"> 2011</option><option value="2010"> 2010</option><option value="2009"> 2009</option><option value="2008"> 2008</option><option value="2007"> 2007</option><option value="2006"> 2006</option><option value="2005"> 2005</option><option value="2004"> 2004</option><option value="2003"> 2003</option><option value="2002"> 2002</option><option value="2001"> 2001</option><option value="2000"> 2000</option><option value="1999"> 1999</option><option value="1998"> 1998</option><option value="1997"> 1997</option><option value="1996"> 1996</option><option value="1995"> 1995</option><option value="1994"> 1994</option><option value="1993"> 1993</option><option value="1992"> 1992</option><option value="1991"> 1991</option><option value="1990"> 1990</option><option value="1989"> 1989</option><option value="1988"> 1988</option><option value="1987"> 1987</option><option value="1986"> 1986</option><option value="1985"> 1985</option><option value="1984"> 1984</option><option value="1983"> 1983</option><option value="1982"> 1982</option><option value="1981"> 1981</option><option value="1980"> 1980</option><option value="1979"> 1979</option><option value="1978"> 1978</option><option value="1977"> 1977</option><option value="1976"> 1976</option><option value="1975"> 1975</option><option value="1974"> 1974</option><option value="1973"> 1973</option><option value="1972"> 1972</option><option value="1971"> 1971</option><option value="1970"> 1970</option><option value="1969"> 1969</option><option value="1968"> 1968</option><option value="1967"> 1967</option><option value="1966"> 1966</option><option value="1965"> 1965</option><option value="1964"> 1964</option><option value="1963"> 1963</option><option value="1962"> 1962</option><option value="1961"> 1961</option><option value="1960"> 1960</option><option value="1959"> 1959</option><option value="1958"> 1958</option><option value="1957"> 1957</option><option value="1956"> 1956</option><option value="1955"> 1955</option><option value="1954"> 1954</option><option value="1953"> 1953</option><option value="1952"> 1952</option><option value="1951"> 1951</option><option value="1950"> 1950</option><option value="1949"> 1949</option><option value="1948"> 1948</option><option value="1947"> 1947</option><option value="1946"> 1946</option><option value="1945"> 1945</option><option value="1944"> 1944</option><option value="1943"> 1943</option><option value="1942"> 1942</option><option value="1941"> 1941</option><option value="1940"> 1940</option><option value="1939"> 1939</option><option value="1938"> 1938</option><option value="1937"> 1937</option><option value="1936"> 1936</option><option value="1935"> 1935</option><option value="1934"> 1934</option><option value="1933"> 1933</option><option value="1932"> 1932</option><option value="1931"> 1931</option><option value="1930"> 1930</option><option value="1929"> 1929</option><option value="1928"> 1928</option><option value="1927"> 1927</option><option value="1926"> 1926</option><option value="1925"> 1925</option><option value="1924"> 1924</option><option value="1923"> 1923</option><option value="1922"> 1922</option><option value="1921"> 1921</option><option value="1920"> 1920</option><option value="1919"> 1919</option><option value="1918"> 1918</option><option value="1917"> 1917</option><option value="1916"> 1916</option><option value="1915"> 1915</option><option value="1914"> 1914</option><option value="1913"> 1913</option><option value="1912"> 1912</option><option value="1911"> 1911</option><option value="1910"> 1910</option><option value="1909"> 1909</option><option value="1908"> 1908</option><option value="1907"> 1907</option><option value="1906"> 1906</option><option value="1905"> 1905</option><option value="1904"> 1904</option><option value="1903"> 1903</option><option value="1902"> 1902</option><option value="1901"> 1901</option>                                                    </select>
                                                </div>
                                            </div>
                                        </div>
                                    </div>
                                </fieldset>

                                <fieldset class="pb-3 pb-md-0 text-center" id="div_deceased_relationship">
                                    <div class="col-md-12">
                                        <span><strong>What is your relationship to your loved one?</strong></span><br>
                                                                                <select name="deceased_relationship" id="deceased_relationship" class="form-control-lg" style="width:75% !important;margin-left:auto;margin-right:auto;">
                                            <option value="" selected="selected" style="font-size: 14px;">[ Select ]
                                            </option>
                                            <option value="N/A" hidden=""></option>
                                                                                            <option value="daughter">
                                                    Daughter                                                </option>
                                                                                            <option value="father">
                                                    Father                                                </option>
                                                                                            <option value="legal_representative">
                                                    Legal Representative                                                </option>
                                                                                            <option value="mother">
                                                    Mother                                                </option>
                                                                                            <option value="sibling">
                                                    Sibling                                                </option>
                                                                                            <option value="son">
                                                    Son                                                </option>
                                                                                            <option value="spouse">
                                                    Spouse                                                </option>
                                                                                            <option value="other ">
                                                    Other                                                </option>
                                                                                    </select>
                                    </div>
                                </fieldset>

                                <fieldset class="pb-3 pb-md-0 text-center" id="div_injured_party_name">
                                    <div class="row">
                                        <div class="col-md-12">
                                            <span>
                                                <strong>What is the injured party's name?</strong>
                                            </span>
                                            <br>
                                        </div>
                                        <div class="row input-group mb-0">
                                            <div class="col-md-12">
                                                <input type="text" class="form-control form-control-lg" id="injured_name" name="injured_name" placeholder="Full Name" pattern="^([a-zA-Z]+\s?\b){2,}" value="" style="width: 100% !important;">
                                            </div>
                                        </div>
                                    </div>
                                </fieldset>

                                <fieldset class="pb-3 pb-md-0 text-center" id="div_signature_authority">
                                    <div class="form-check">
                                        <span><strong>Do you have legal authority to sign on their behalf?</strong></span><br>
                                        <input type="radio" class="btn-check" id="signature_authority_yes" name="signature_authority" autocomplete="off" value="1">
                                        <label class="btn btn-primary" for="signature_authority_yes" style="width:100%;border:solid grey 1px;">Yes</label><br>
                                        <input type="radio" class="btn-check" id="signature_authority_no" name="signature_authority" autocomplete="off" value="0">
                                        <label class="btn btn-primary" for="signature_authority_no" style="width:100%;border:solid grey 1px;">No</label>
                                        <input type="radio" class="btn-check" id="signature_authority_na" name="signature_authority" autocomplete="off" value="N/A" hidden="">
                                    </div>
                                </fieldset>
                                <fieldset class="pb-3 pb-md-0 text-center" id="div_have_poa">
                                    <div class="form-check">
                                        <span><strong>Do you have a Power of Attorney (POA)?</strong></span><br>
                                        <input type="radio" class="btn-check" id="have_poa_yes" name="have_poa" autocomplete="off" value="1">
                                        <label class="btn btn-primary" for="have_poa_yes" style="width:100%;border:solid grey 1px;">Yes</label><br>
                                        <input type="radio" class="btn-check" id="have_poa_no" name="have_poa" autocomplete="off" value="0">
                                        <label class="btn btn-primary" for="have_poa_no" style="width:100%;border:solid grey 1px;">No</label>
                                        <input type="radio" class="btn-check" id="have_poa_na" name="have_poa" autocomplete="off" value="N/A" hidden="">
                                    </div>
                                </fieldset>


                                <fieldset class="pb-3 pb-md-0 text-center" id="div_suffered">
                                    <div class="form-check">
                                        <span><strong>Have you or your loved one suffered harm as a result of water contamination at Camp Lejeune?</strong></span><br>
                                        <input type="radio" class="btn-check" id="suffered_yes" name="suffered" autocomplete="off" value="1">
                                        <label class="btn btn-primary" for="suffered_yes" style="width:100%;border:solid grey 1px;">Yes</label><br>
                                        <input type="radio" class="btn-check" id="suffered_no" name="suffered" autocomplete="off" value="0">
                                        <label class="btn btn-primary" for="suffered_no" style="width:100%;border:solid grey 1px;">No</label>
                                    </div>
                                </fieldset>

                                <fieldset class="pb-3 pb-md-0 text-center" id="div_diagnosis_year">
                                    <div class="row">
                                        <span><strong>What year were you/injured party diagnosed with your claimed injury?</strong></span>
                                        <select name="diagnosis_year" id="diagnosis_year" class="form-select form-select-lg mb-3" style="width:75% !important;margin-left:auto!important;margin-right:auto!important;">
                                            <option value="">[Select Year]</option>
                                            <option value="2022">2022</option><option value="2021">2021</option><option value="2020">2020</option><option value="2019">2019</option><option value="2018">2018</option><option value="2017">2017</option><option value="2016">2016</option><option value="2015">2015</option><option value="2014">2014</option><option value="2013">2013</option><option value="2012">2012</option><option value="2011">2011</option><option value="2010">2010</option><option value="2009">2009</option><option value="2008">2008</option><option value="2007">2007</option><option value="2006">2006</option><option value="2005">2005</option><option value="2004">2004</option><option value="2003">2003</option><option value="2002">2002</option><option value="2001">2001</option><option value="2000">2000</option><option value="1999">1999</option><option value="1998">1998</option><option value="1997">1997</option><option value="1996">1996</option><option value="1995">1995</option><option value="1994">1994</option><option value="1993">1993</option><option value="1992">1992</option><option value="1991">1991</option><option value="1990">1990</option><option value="1989">1989</option><option value="1988">1988</option><option value="1987">1987</option><option value="1986">1986</option><option value="1985">1985</option><option value="1984">1984</option><option value="1983">1983</option><option value="1982">1982</option><option value="1981">1981</option><option value="1980">1980</option><option value="1979">1979</option><option value="1978">1978</option><option value="1977">1977</option><option value="1976">1976</option><option value="1975">1975</option><option value="1974">1974</option><option value="1973">1973</option><option value="1972">1972</option><option value="1971">1971</option><option value="1970">1970</option><option value="1969">1969</option><option value="1968">1968</option><option value="1967">1967</option><option value="1966">1966</option><option value="1965">1965</option><option value="1964">1964</option><option value="1963">1963</option><option value="1962">1962</option><option value="1961">1961</option><option value="1960">1960</option><option value="1959">1959</option><option value="1958">1958</option><option value="1957">1957</option><option value="1956">1956</option><option value="1955">1955</option><option value="1954">1954</option><option value="1953">1953</option>                                        </select>
                                    </div>
                                </fieldset>

                                <fieldset class="pb-3 pb-md-0 text-center" id="div_diagnosis_location">
                                    <div class="row">
                                        <span><strong>What hospital/doctor and city &amp; state were you/injured party diagnosed in?</strong></span>
                                        <div class="row input-group mb-0">
                                            <div class="col-md-6">
                                                <input type="text" class="form-control form-control-lg " id="diagnosis_hospital" name="diagnosis_hospital" placeholder="Hospital Name/Doctor" value="" style="width: 100% !important;">
                                            </div>
                                            <div class="col-md-3">
                                                <input type="text" class="form-control form-control-lg " id="diagnosis_city" name="diagnosis_city" placeholder="City" value="" style="width: 100% !important;">
                                            </div>
                                            <div class="col-md-3">
                                                <select type="text" class="form-control-lg" id="diagnosis_state" name="diagnosis_state" placeholder="State" value="" style="width: 100% !important;">
                                                    <option value="">State</option>
                                                    <option value="AL">Alabama</option>
                                                    <option value="AK">Alaska</option>
                                                    <option value="AZ">Arizona</option>
                                                    <option value="AR">Arkansas</option>
                                                    <option value="CA">California</option>
                                                    <option value="CO">Colorado</option>
                                                    <option value="CT">Connecticut</option>
                                                    <option value="DE">Delaware</option>
                                                    <option value="DC">District Of Columbia</option>
                                                    <option value="FL">Florida</option>
                                                    <option value="GA">Georgia</option>
                                                    <option value="HI">Hawaii</option>
                                                    <option value="ID">Idaho</option>
                                                    <option value="IL">Illinois</option>
                                                    <option value="IN">Indiana</option>
                                                    <option value="IA">Iowa</option>
                                                    <option value="KS">Kansas</option>
                                                    <option value="KY">Kentucky</option>
                                                    <option value="LA">Louisiana</option>
                                                    <option value="ME">Maine</option>
                                                    <option value="MD">Maryland</option>
                                                    <option value="MA">Massachusetts</option>
                                                    <option value="MI">Michigan</option>
                                                    <option value="MN">Minnesota</option>
                                                    <option value="MS">Mississippi</option>
                                                    <option value="MO">Missouri</option>
                                                    <option value="MT">Montana</option>
                                                    <option value="NE">Nebraska</option>
                                                    <option value="NV">Nevada</option>
                                                    <option value="NH">New Hampshire</option>
                                                    <option value="NJ">New Jersey</option>
                                                    <option value="NM">New Mexico</option>
                                                    <option value="NY">New York</option>
                                                    <option value="NC">North Carolina</option>
                                                    <option value="ND">North Dakota</option>
                                                    <option value="OH">Ohio</option>
                                                    <option value="OK">Oklahoma</option>
                                                    <option value="OR">Oregon</option>
                                                    <option value="PA">Pennsylvania</option>
                                                    <option value="RI">Rhode Island</option>
                                                    <option value="SC">South Carolina</option>
                                                    <option value="SD">South Dakota</option>
                                                    <option value="TN">Tennessee</option>
                                                    <option value="TX">Texas</option>
                                                    <option value="UT">Utah</option>
                                                    <option value="VT">Vermont</option>
                                                    <option value="VA">Virginia</option>
                                                    <option value="WA">Washington</option>
                                                    <option value="WV">West Virginia</option>
                                                    <option value="WI">Wisconsin</option>
                                                    <option value="WY">Wyoming</option>
                                                </select>
                                            </div>
                                        </div>
                                    </div>
                                </fieldset>

                                <fieldset class="pb-3 pb-md-0" id="div_reason">
                                    <div class="row">
                                        <div class="col-md-12">
                                            <span><strong>Please select the reason for being at Camp Lejeune:</strong></span><br>
                                                                                        <select name="reason" id="reason" class="form-control-lg" style="width:75% !important;margin-left:auto;margin-right:auto">
                                                <option value="" selected="selected" style="">[ Select ]
                                                </option>
                                                                                                    <option value="lived">
                                                        Lived                                                    </option>
                                                                                                    <option value="served">
                                                        Served                                                    </option>
                                                                                                    <option value="worked">
                                                        Worked                                                    </option>
                                                                                            </select>
                                        </div>
                                    </div>
                                </fieldset>

                                <fieldset class="pb-1 pb-md-0" id="div_unit_lived">
                                    <div class="row">
                                        <div class="col-md-12">
                                            <span><strong>What barracks/housing unit did you reside at Camp Lejeune?</strong></span><br>
                                                                                        <select name="unit_lived" id="unit_lived" class="form-control-lg" style="width:75% !important;margin-left:auto;margin-right:auto">
                                                <option value="" selected="selected" style="">[ Select ]
                                                </option>
                                                <option value="N/A" hidden=""></option>
                                                                                                    <option value="bachelor_housing">
                                                        Bachelor Housing                                                    </option>
                                                                                                    <option value="berkeley_manor">
                                                        Berkeley Manor                                                    </option>
                                                                                                    <option value="camp_knox">
                                                        Camp Knox                                                    </option>
                                                                                                    <option value="hospital_point">
                                                        Hospital Point                                                    </option>
                                                                                                    <option value="midway_park">
                                                        Midway Park                                                    </option>
                                                                                                    <option value="paradise_point">
                                                        Paradise Point                                                    </option>
                                                                                                    <option value="tarawa_terrace">
                                                        Tarawa Terrace                                                    </option>
                                                                                                    <option value="wadkins_village">
                                                        Wadkins Village                                                    </option>
                                                                                            </select>
                                        </div>
                                    </div>
                                </fieldset>

                                <fieldset class="pb-3 pb-md-0" id="div_length_lived">
                                    <div class="form-check">
                                        <span><strong>Were you at Camp Lejeune for at least 30 days?</strong></span><br>
                                        <input type="radio" class="btn-check length_lived" id="length_lived_yes" name="length_lived" autocomplete="off" value="1">
                                        <label class="btn btn-primary" for="length_lived_yes" style="width:100%;border:solid grey 1px;">Yes</label><br>
                                        <input type="radio" class="btn-check used_talcum" id="length_lived_no" name="length_lived" autocomplete="off" value="0">
                                        <label class="btn btn-primary" for="length_lived_no" style="width:100%;border:solid grey 1px;">No</label>
                                    </div>
                                </fieldset>

                                <fieldset class="pb-1 pb-md-0" id="div_first_year">
                                    <div class="col-md-12">
                                        <span><strong>Please select you or your loved one's first year at Camp Lejeune:</strong></span><br>
                                        <select name="first_year" id="first_year" vtype="not_empty" vclass="not_show" class="form-select form-control-lg" style="width:75% !important;margin-left:auto!important;margin-right:auto!important;">
                                            <option value="">[Select Year]</option>
                                            <option value="2022">2022</option><option value="2021">2021</option><option value="2020">2020</option><option value="2019">2019</option><option value="2018">2018</option><option value="2017">2017</option><option value="2016">2016</option><option value="2015">2015</option><option value="2014">2014</option><option value="2013">2013</option><option value="2012">2012</option><option value="2011">2011</option><option value="2010">2010</option><option value="2009">2009</option><option value="2008">2008</option><option value="2007">2007</option><option value="2006">2006</option><option value="2005">2005</option><option value="2004">2004</option><option value="2003">2003</option><option value="2002">2002</option><option value="2001">2001</option><option value="2000">2000</option><option value="1999">1999</option><option value="1998">1998</option><option value="1997">1997</option><option value="1996">1996</option><option value="1995">1995</option><option value="1994">1994</option><option value="1993">1993</option><option value="1992">1992</option><option value="1991">1991</option><option value="1990">1990</option><option value="1989">1989</option><option value="1988">1988</option><option value="1987">1987</option><option value="1986">1986</option><option value="1985">1985</option><option value="1984">1984</option><option value="1983">1983</option><option value="1982">1982</option><option value="1981">1981</option><option value="1980">1980</option><option value="1979">1979</option><option value="1978">1978</option><option value="1977">1977</option><option value="1976">1976</option><option value="1975">1975</option><option value="1974">1974</option><option value="1973">1973</option><option value="1972">1972</option><option value="1971">1971</option><option value="1970">1970</option><option value="1969">1969</option><option value="1968">1968</option><option value="1967">1967</option><option value="1966">1966</option><option value="1965">1965</option><option value="1964">1964</option><option value="1963">1963</option><option value="1962">1962</option><option value="1961">1961</option><option value="1960">1960</option><option value="1959">1959</option><option value="1958">1958</option><option value="1957">1957</option><option value="1956">1956</option><option value="1955">1955</option><option value="1954">1954</option><option value="1953">1953</option><option value="1952">1952</option><option value="1951">1951</option><option value="1950">1950</option><option value="1949">1949</option><option value="1948">1948</option><option value="1947">1947</option><option value="1946">1946</option><option value="1945">1945</option><option value="1944">1944</option><option value="1943">1943</option><option value="1942">1942</option>                                        </select>
                                    </div>
                                </fieldset>

                                <fieldset class="pb-1 pb-md-0" id="div_last_year">
                                    <div class="col-md-12">
                                        <span><strong>Please select you or your loved one's last year at Camp Lejeune:</strong></span><br>
                                        <select name="last_year" id="last_year" vtype="not_empty" vclass="not_show" class="form-select form-control-lg" style="width:75% !important;margin-left:auto!important;margin-right:auto!important;">
                                            <option value="">[Select Year]</option>
                                            <option value="2022">2022</option><option value="2021">2021</option><option value="2020">2020</option><option value="2019">2019</option><option value="2018">2018</option><option value="2017">2017</option><option value="2016">2016</option><option value="2015">2015</option><option value="2014">2014</option><option value="2013">2013</option><option value="2012">2012</option><option value="2011">2011</option><option value="2010">2010</option><option value="2009">2009</option><option value="2008">2008</option><option value="2007">2007</option><option value="2006">2006</option><option value="2005">2005</option><option value="2004">2004</option><option value="2003">2003</option><option value="2002">2002</option><option value="2001">2001</option><option value="2000">2000</option><option value="1999">1999</option><option value="1998">1998</option><option value="1997">1997</option><option value="1996">1996</option><option value="1995">1995</option><option value="1994">1994</option><option value="1993">1993</option><option value="1992">1992</option><option value="1991">1991</option><option value="1990">1990</option><option value="1989">1989</option><option value="1988">1988</option><option value="1987">1987</option><option value="1986">1986</option><option value="1985">1985</option><option value="1984">1984</option><option value="1983">1983</option><option value="1982">1982</option><option value="1981">1981</option><option value="1980">1980</option><option value="1979">1979</option><option value="1978">1978</option><option value="1977">1977</option><option value="1976">1976</option><option value="1975">1975</option><option value="1974">1974</option><option value="1973">1973</option><option value="1972">1972</option><option value="1971">1971</option><option value="1970">1970</option><option value="1969">1969</option><option value="1968">1968</option><option value="1967">1967</option><option value="1966">1966</option><option value="1965">1965</option><option value="1964">1964</option><option value="1963">1963</option><option value="1962">1962</option><option value="1961">1961</option><option value="1960">1960</option><option value="1959">1959</option><option value="1958">1958</option><option value="1957">1957</option><option value="1956">1956</option><option value="1955">1955</option><option value="1954">1954</option><option value="1953">1953</option><option value="1952">1952</option><option value="1951">1951</option><option value="1950">1950</option><option value="1949">1949</option><option value="1948">1948</option><option value="1947">1947</option><option value="1946">1946</option><option value="1945">1945</option><option value="1944">1944</option><option value="1943">1943</option><option value="1942">1942</option>                                        </select>
                                    </div>
                                </fieldset>

                                <fieldset class="pb-1 pb-md-0" id="div_dob">
                                    <div class="row">
                                        <div class="col-md-12">
                                            <span><strong>Please enter injured party date of birth.</strong></span><br>
                                            <div class="row">
                                                <div class="col-md-4">
                                                    <select id="edit_dob_month" name="edit_dob_month" class="form-select form-dob-select" vtype="not_empty" style="width: 100% !important;">
                                                        <option value="" selected="selected">Month</option>
                                                        <option value="01"> Jan</option>
                                                        <option value="02"> Feb</option>
                                                        <option value="03"> Mar</option>
                                                        <option value="04"> Apr</option>
                                                        <option value="05"> May</option>
                                                        <option value="06"> Jun</option>
                                                        <option value="07"> Jul</option>
                                                        <option value="08"> Aug</option>
                                                        <option value="09"> Sep</option>
                                                        <option value="10"> Oct</option>
                                                        <option value="11"> Nov</option>
                                                        <option value="12"> Dec</option>
                                                    </select>

                                                </div>

                                                <div class="col-md-4">
                                                    <select id="edit_dob_day" name="edit_dob_day" class="form-select form-dob-select" vtype="not_empty" style="width: 100% !important;">
                                                        <option value="" selected="selected">Day</option>
                                                        <option value="01"> 1</option><option value="02"> 2</option><option value="03"> 3</option><option value="04"> 4</option><option value="05"> 5</option><option value="06"> 6</option><option value="07"> 7</option><option value="08"> 8</option><option value="09"> 9</option><option value="10"> 10</option><option value="11"> 11</option><option value="12"> 12</option><option value="13"> 13</option><option value="14"> 14</option><option value="15"> 15</option><option value="16"> 16</option><option value="17"> 17</option><option value="18"> 18</option><option value="19"> 19</option><option value="20"> 20</option><option value="21"> 21</option><option value="22"> 22</option><option value="23"> 23</option><option value="24"> 24</option><option value="25"> 25</option><option value="26"> 26</option><option value="27"> 27</option><option value="28"> 28</option><option value="29"> 29</option><option value="30"> 30</option><option value="31"> 31</option>                                                    </select>
                                                </div>

                                                <div class="col-md-4">
                                                    <select id="edit_dob_year" name="edit_dob_year" class="form-select form-dob-select" vtype="not_empty" style="width: 100% !important;">
                                                        <option value="">Year</option>
                                                        <option value="2004"> 2004</option><option value="2003"> 2003</option><option value="2002"> 2002</option><option value="2001"> 2001</option><option value="2000"> 2000</option><option value="1999"> 1999</option><option value="1998"> 1998</option><option value="1997"> 1997</option><option value="1996"> 1996</option><option value="1995"> 1995</option><option value="1994"> 1994</option><option value="1993"> 1993</option><option value="1992"> 1992</option><option value="1991"> 1991</option><option value="1990"> 1990</option><option value="1989"> 1989</option><option value="1988"> 1988</option><option value="1987"> 1987</option><option value="1986"> 1986</option><option value="1985"> 1985</option><option value="1984"> 1984</option><option value="1983"> 1983</option><option value="1982"> 1982</option><option value="1981"> 1981</option><option value="1980"> 1980</option><option value="1979"> 1979</option><option value="1978"> 1978</option><option value="1977"> 1977</option><option value="1976"> 1976</option><option value="1975"> 1975</option><option value="1974"> 1974</option><option value="1973"> 1973</option><option value="1972"> 1972</option><option value="1971"> 1971</option><option value="1970"> 1970</option><option value="1969"> 1969</option><option value="1968"> 1968</option><option value="1967"> 1967</option><option value="1966"> 1966</option><option value="1965"> 1965</option><option value="1964"> 1964</option><option value="1963"> 1963</option><option value="1962"> 1962</option><option value="1961"> 1961</option><option value="1960"> 1960</option><option value="1959"> 1959</option><option value="1958"> 1958</option><option value="1957"> 1957</option><option value="1956"> 1956</option><option value="1955"> 1955</option><option value="1954"> 1954</option><option value="1953"> 1953</option><option value="1952"> 1952</option><option value="1951"> 1951</option><option value="1950"> 1950</option><option value="1949"> 1949</option><option value="1948"> 1948</option><option value="1947"> 1947</option><option value="1946"> 1946</option><option value="1945"> 1945</option><option value="1944"> 1944</option><option value="1943"> 1943</option><option value="1942"> 1942</option><option value="1941"> 1941</option><option value="1940"> 1940</option><option value="1939"> 1939</option><option value="1938"> 1938</option><option value="1937"> 1937</option><option value="1936"> 1936</option><option value="1935"> 1935</option><option value="1934"> 1934</option><option value="1933"> 1933</option><option value="1932"> 1932</option><option value="1931"> 1931</option><option value="1930"> 1930</option><option value="1929"> 1929</option><option value="1928"> 1928</option><option value="1927"> 1927</option><option value="1926"> 1926</option><option value="1925"> 1925</option><option value="1924"> 1924</option><option value="1923"> 1923</option><option value="1922"> 1922</option><option value="1921"> 1921</option><option value="1920"> 1920</option><option value="1919"> 1919</option><option value="1918"> 1918</option><option value="1917"> 1917</option><option value="1916"> 1916</option><option value="1915"> 1915</option><option value="1914"> 1914</option><option value="1913"> 1913</option><option value="1912"> 1912</option><option value="1911"> 1911</option><option value="1910"> 1910</option><option value="1909"> 1909</option><option value="1908"> 1908</option><option value="1907"> 1907</option><option value="1906"> 1906</option><option value="1905"> 1905</option><option value="1904"> 1904</option><option value="1903"> 1903</option><option value="1902"> 1902</option><option value="1901"> 1901</option>                                                    </select>
                                                </div>
                                            </div>
                                        </div>
                                    </div>
                                </fieldset>

                                <fieldset class="pb-3 pb-md-0" id="div_administrative_claim">
                                    <div class="form-check">
                                        <span><strong>Have you filed an administrative claim for Camp Lejeune benefits?</strong></span><br>
                                        <input type="radio" class="btn-check" id="administrative_claim_yes" name="administrative_claim" autocomplete="off" value="1">
                                        <label class="btn btn-primary" for="administrative_claim_yes" style="width:100%;border:solid grey 1px;">Yes</label><br>
                                        <input type="radio" class="btn-check" id="administrative_claim_no" name="administrative_claim" autocomplete="off" value="0">
                                        <label class="btn btn-primary" for="administrative_claim_no" style="width:100%;border:solid grey 1px;">No</label>
                                    </div>
                                </fieldset>

                                <fieldset class="pb-3 pb-md-0" id="div_claim_date">
                                    <div class="row">
                                        <span><strong>What date did you file?</strong></span>
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        <h1 class="mb-4">ABOUT CAMP LEJEUNE WATER CONTAMINATION LAWSUITS</h1>
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            Camp Lejeune is a massive Marine Corps base and military training facility that covers nearly 250 square
            miles in Onslow County, North Carolina. Camp Lejeune was first opened in 1942. It has been used as both a
            base of operations for the Marine Corps and a military operations and training facility used by various
            branches of the armed forces. Since its founding in 1942, Camp Lejeune has been a temporary or permanent
            home for thousands of military service members and their families. It has also been a home or place of work
            for thousands more civilian employees and contractors. Camp Lejeune had its own public water system to
            supply these soldiers and civilians with potable water.
        </p>
        <p style="font-family: 'Lucida Grande', 'Lucida Sans Unicode', 'Lucida Sans', 'DejaVu Sans', Verdana, 'sans-serif'; text-align: left ">
            Routine water testing in 1982 found that drinking water sources at Camp Lejeune were contaminated with
            benzene, trichloroethylene (TCE), tetrachloroethylene, or perchloroethylene (PCE), and vinyl chloride (VC),
            all of which are known to be carcinogenic or harmful to humans. Contamination of water was documented at up
            to 300 times acceptable levels in some cases. The main chemicals involved were volatile organic compounds
            (VOCs), however, more than 70 chemicals have been identified as contaminants at Camp Lejeune.
        </p>

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            Camp Lejeune Justice Act of 2022:
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        <p style="font-family: 'Lucida Grande', 'Lucida Sans Unicode', 'Lucida Sans', 'DejaVu Sans', Verdana, 'sans-serif'; text-align: left ">
            The Camp Lejeune Justice Act of 2022 is a bipartisan bill intended to ensure that individuals – veterans,
            their family members or other individuals living or working at the base between 1953 and 1987 – who were
            harmed by water contamination at Camp Lejeune receive fair compensation. Many of these individuals have had
            their claims inappropriately denied or delayed, resulting in additional harm.
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        <p style="font-family: 'Lucida Grande', 'Lucida Sans Unicode', 'Lucida Sans', 'DejaVu Sans', Verdana, 'sans-serif'; text-align: left ">
            The Bill is making its way through Congress as part of the Honoring Our PACT Act of 2022, which passed the
            U.S. House of Representatives on March 4, 2022. The Act will permit people who worked, lived, or were
            exposed in-utero, to contaminated water at Camp Lejeune between 1953 and 1987, to file a claim in U.S.
            federal court.
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            June 16, 2022, Camp Lejeune Legislative Update:
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            Republicans and Democrats came together today in a resounding 84-16 vote for the 19 million veterans in the
            U.S. today, we look forward to working with all lawyers and legal vendors who share the goal of settling the
            debts owed to the millions of veterans who served and sacrificed on our country’s behalf.
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                    For over 30 years, Marines and personnel of any branch of the armed forces and their families
                    stationed at Camp Lejeune's main base, barracks, family, temporary housing, Tarawa Terrace, and
                    Hadnot Point drank and bathed in water contaminated with toxins at concentrations from 240 to 3400
                    times levels permitted by safety standards.
                    <br>
                    Camp Lejeune water contamination sources included leaking underground water storage tanks and waste
                    disposal sites. The contaminated wells were mostly closed by February 1985; however, those who
                    had been exposed have faced cancer and other serious health problems related to the chemicals. Side
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                    <li>Bladder Cancer</li>
                    <li>Breast Cancer</li>
                    <li>Cardiac Birth Defects</li>
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                    <li>Esophageal Cancer</li>
                    <li>Hepatic Steatosis</li>
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                    <li>Lung Cancer</li>
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                    <li>Multiple Myeloma</li>
                    <li>Myelodysplastic Syndromes (MDS)</li>
                    <li>Neurobehavioral Effects</li>
                    <li>Non-Hodgkin's Lymphoma (NHL)</li>
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                <h2 class="mt-0">TAKE ACTION</h2>
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                    Most Camp Lejeune victims have previously not had access to the kind of compensation needed to take
                    care of their and their families' injuries. The Camp Lejeune Justice Act of 2022 may now allow
                    victims to recover significant compensation.
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                    If you lived or worked at Camp Lejeune between 1953 and 1987 and developed cancer or another serious
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                    <a style="color:blue;overflow-wrap:break-word;word-wrap:break-word;" href="https://www.lawsuit-information-center.com/camp-lejeune-water-lawsuit.html" target="_blank" rel="noopener">
                        Lawsuit Information Center - Camp Lejeune Lawsuit - June 16, 2022
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    var RESOURCES = ["https:\/\/ajax.googleapis.com\/ajax\/libs\/jquery\/2.2.4\/jquery.min.js","vendor\/jquery-easing\/jquery.easing.min.js","https:\/\/lawsuit-winning.com\/_lco\/js\/bundle.php?light=1&track=0&localize=1&localize_domain=lawsuit-winning.com\/_lco","js\/multi-step.js","\/js\/site-js-bundle.php","js\/form-step.js"];
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    var CUSTOM_TAGS = ["<script id=\"LeadiDscript\" type=\"text\/javascript\">\r\n\/\/ <!--\r\n(function() {\r\nvar s = document.createElement('script');\r\ns.id = 'LeadiDscript_campaign';\r\ns.type = 'text\/javascript';\r\ns.async = true;\r\ns.src = '\/\/create.lidstatic.com\/campaign\/37899f90-5697-3e49-95f3-1d8d0457812f.js?snippet_version=2';\r\nvar LeadiDscript = document.getElementById('LeadiDscript');\r\nLeadiDscript.parentNode.insertBefore(s, LeadiDscript);\r\n})();\r\n\/\/ -->\r\n<\/script>\r\n<noscript><img src='\/\/create.leadid.com\/noscript.gif?lac=c225f2e6-f60c-b10e-a931-5ee1838f1875&lck=37899f90-5697-3e49-95f3-1d8d0457812f&snippet_version=2' \/><\/noscript>\r\n\r\n\r\n<link rel=\"dns-prefetch\" href=\"\/\/api.trustedform.com\"><script type=\"text\/javascript\" >setTimeout(function() {var field = 'xxTrustedFormCertUrl';var provideReferrer = false;var invertFieldSensitivity = false;var tf = document.createElement('script');tf.type = 'text\/javascript'; tf.async = true;tf.src = '\/\/api.trustedform.com\/trustedform.js?provide_referrer=' + escape(provideReferrer) + '&field=' + escape(field) + '&l='+new Date().getTime()+Math.random() + '&invert_field_sensitivity=' + invertFieldSensitivity;document.body.appendChild(tf);}, 1000);<\/script><noscript><img src=\"\/\/api.trustedform.com\/ns.gif\" \/><\/noscript>","\r\n<script async src='\/_content\/offers\/d_notifyai.js'><\/script>      <script type='text\/javascript'> setTimeout ( function () { var notifyai_lid = ''; if ( typeof edit_lead_instance_id === 'object' && edit_lead_instance_id != undefined && edit_lead_instance_id !== null ) { notifyai_lid = document.getElementById('edit_lead_instance_id').value; } d_notifyai_load_script('https:\/\/beachsidebay.com\/?a=1221&c=36485&cp=js&s1=LSW&s2=' + notifyai_lid + '&s3=' + d_notifyai_get_parameter_by_name('afid') + '&s4=' + d_notifyai_get_parameter_by_name('sid1') + '&s5=' + d_notifyai_get_parameter_by_name('sid2')); }, 500); <\/script>      <script> (function(document, window) { var script = document.createElement(\"script\"); script.type = \"text\/javascript\"; script.src = \"https:\/\/secureanalytic.com\/scripts\/push\/script\/57dkpo9gw8?url=\" + encodeURI(self.location.hostname); script.onload = function() { push_init(); setTimeout(function() { var input = document.createElement('input');  input.setAttribute('type', 'hidden'); input.setAttribute('name', 'notifyai_crid'); input.setAttribute('id', 'notifyai_crid'); if ( typeof ckm_request_id !== 'object' || ckm_request_id == undefined || ckm_request_id === null ) { ckm_request_id = ''; } input.setAttribute ( 'value', ckm_request_id ); document.getElementsByTagName('body')[0].appendChild(input);                    \nvar utmObj = {\n \"utm_source\": window.location.hostname,\n \"source_one\": d_notifyai_get_parameter_by_name('afid'),\n \"source_two\": d_notifyai_get_parameter_by_name('sid1'),\n \"source_three\": d_notifyai_get_parameter_by_name('sid2'),\n \"source_four\": d_notifyai_get_parameter_by_name('sid3'),\n \"source_five\": document.getElementById('notifyai_crid').value\n}\nsetUtm(utmObj);console.log(utmObj);\n}, 2000); push_subscribe(); }; document.getElementsByTagName(\"head\")[0].appendChild(script); })(document, window); <\/script>","<script>\r\n(function(i,s,o,g,r,a,m){i['GoogleAnalyticsObject']=r;i[r]=i[r]||function(){\r\n(i[r].q=i[r].q||[]).push(arguments)},i[r].l=1*new Date();a=s.createElement(o),\r\nm=s.getElementsByTagName(o)[0];a.async=1;a.src=g;setTimeout(function() { document.body.appendChild(a) },1000);\r\n})(window,document,'script','\/\/www.google-analytics.com\/analytics.js','ga');\r\nga('create', 'UA-47887005-8', 'auto');\r\nga('send', 'pageview');\r\n<\/script>\r\n"];

    function loadScript(url) {
        return new Promise(function(resolve, reject) {
            var script = document.createElement('script');
            script.onload = function () {
                //setTimeout(function() {
                resolve(true);
                //},1000);
            };
            script.src = url;
            script.async = 1;
            script.defer = 1;
            document.body.appendChild(script);
        });
    }

     function parseCustomTag(tag) {
         // parse for script tags that need to execute in document
         var doc = document.implementation.createHTMLDocument(); // Sandbox
         doc.body.innerHTML = tag; // Parse HTML properly
         [].map.call(doc.getElementsByTagName('script'), function(el) {
             var script = document.createElement("script");
             if (el.id) {
                 script.id = el.id;
             }
             script.async = true;
             if (el.textContent.length>0) {
                 script.text = el.textContent;
             }
             if (el.src.length > 0) {
                 script.src = el.src;
             }
             document.body.appendChild(script);
             return el.textContent;
         });
     }

     function loadCustomTags(custom_tags) {
         return new Promise(function(resolve) {
             setTimeout(function() {
                 custom_tags.forEach(function(tag) {
                     if (tag.length === 0) {
                         return false;
                     }
                     parseCustomTag(tag);
                 });
                 resolve();
             },3000);
         });
     }

    function loadCustomTags(custom_tags) {
        return new Promise(function(resolve) {
            setTimeout(function() {
                custom_tags.forEach(function(tag) {
                    if (tag.length === 0) {
                        return false;
                    }
                    // parse for script tags that need to execute in document
                    var doc = document.implementation.createHTMLDocument(); // Sandbox
                    doc.body.innerHTML = tag; // Parse HTML properly
                    [].map.call(doc.getElementsByTagName('script'), function(el) {
                        var script = document.createElement("script");
                        if (el.id) {
                            script.id = el.id;
                        }
                        script.async = true;
                        if (el.textContent.length>0) {
                            script.text = el.textContent;
                        }
                        if (el.src.length > 0) {
                            script.src = el.src;
                        }
                        document.body.appendChild(script);
                        return el.textContent;
                    });
                    // insert tag as it is (seems like overkill, we rely heavily on JS)
                    //document.body.appendChild(tag);
                });
                resolve();
            },3000);
        });
    }

    document.addEventListener('DOMContentLoaded', function() {
             var resources = [... [], ... RESOURCES]; // create copy of array to manipulate for promise chain
             var entry = resources.shift(); // pull first asset, which is likely JQuery

             function init() {
                 // parse first party scripts needed for LP
                 resources.reduce(function (p, script) {
                     return p.then(function() {
                         return loadScript(script);
                     })
                 }, Promise.resolve())
                     // execute custom code needed for LP that relies on libraries
                     .then(function(resolve) {
                         // Page Initialization
                             SetPostData ( "" );
                         return true;
                     })
                     // parse and load 3rd party pixels
                     .then(loadCustomTags(CUSTOM_TAGS));
             }

             setTimeout(function () {
                 var script = document.createElement('script');
                 script.onload = function () {
                     try {
                         if (CP_TAG.length > 0) {
                             new Promise(function(resolve) {
                                 parseCustomTag(CP_TAG)
                                 setTimeout(resolve, 500);
                             }).then(function() {
                                 init();
                             })
                         }
                         else {
                             init();
                         }
                     } catch (e) {
                         console.log(e);
                     }
                 };
                 script.src = entry;
                 document.body.appendChild(script);
             }, 250);
         });
</script><script>setTimeout(function(){var o=document.createElement("script");o.onload=function(){window.micAccessTool=new MicAccessTool({buttonPosition:"right"})},o.src="/_lco/js/ada/app/minjs/common.min.js",document.head.appendChild(o)},3e3);</script>
<script type="text/javascript"> adroll_adv_id = "ZBECDUJN55CUJGJFORPUKH"; adroll_pix_id = "T2ZMDKUGXZH4LFZMQSW453"; adroll_version = "2.0";  (function(w, d, e, o, a) { w.__adroll_loaded = true; w.adroll = w.adroll || []; w.adroll.f = [ 'setProperties', 'identify', 'track' ]; var roundtripUrl = "https://s.adroll.com/j/" + adroll_adv_id + "/roundtrip.js"; for (a = 0; a < w.adroll.f.length; a++) { w.adroll[w.adroll.f[a]] = w.adroll[w.adroll.f[a]] || (function(n) { return function() { w.adroll.push([ n, arguments ]) } })(w.adroll.f[a]) }  e = d.createElement('script'); o = d.getElementsByTagName('script')[0]; e.async = 1; e.src = roundtripUrl; o.parentNode.insertBefore(e, o); })(window, document); adroll.track("pageView"); </script> 
<script type="text/javascript"> function addNewHiddenInput(name, value, target = null) { var newInput = document.createElement('input'); newInput.type = 'hidden'; newInput.name = name; newInput.id = name; newInput.value = value; document.getElementById(target ?? 'edit_lead_instance_id').parentElement.appendChild(newInput); } function optionalCallbackFunction(response) { if (response.getId() || response.getExId()) { addNewHiddenInput('anura_id', response.getId()); getResult(response); } } function getResult(response) { var method = 'POST'; var params = ['instance=3605361205']; if (response.getId()) params.push('id='+encodeURIComponent(response.getId())); if (response.getExId()) params.push('exid='+encodeURIComponent(response.getExId())); var url = 'https://script.anura.io/result.json'+('GET' === method ? '?'+params.join('&'): ''); if (window.XMLHttpRequest) { var http = new XMLHttpRequest(); if (http && 'withCredentials' in http) { http.open(method, url, true); if ('POST' === method) http.setRequestHeader('Content-type', 'application/x-www-form-urlencoded'); http.onload = function(){anuraResultHandler(this);}; http.send('POST' === method ? params.join('&'): ''); } } } function anuraResultHandler(http) { var response = JSON.parse(http.response); if(response) { Object.entries(response).forEach(entry => { var [key, val] = entry; addNewHiddenInput('anura_' + key, val); }); } } const queryString = window.location.search; const urlParams = new URLSearchParams(queryString); const afid = urlParams.get('afid'); const sid1 = urlParams.get('sid1'); (function () {  var anura = document.createElement('script');  if ('object' === typeof anura) {  var request = {  instance: 3605361205,  source: afid, campaign: sid1, callback: 'optionalCallbackFunction' };  var params = [];  for (var x in request)  params.push(x + '=' + encodeURIComponent(request[x]));  params.push(Math.floor(1E12 * Math.random() + 1));  anura.type = 'text/javascript';  anura.async = true;  anura.src = 'https://script.anura.io/request.js?' + params.join('&');  var script = document.getElementsByTagName('script')[0];  script.parentNode.insertBefore(anura, script);  } })(); </script>
    <link href="vendor/fontawesome-free/css/all.min.css" rel="stylesheet" as="style" onload="this.onload;this.rel='stylesheet'">
    <noscript>
        <link href="vendor/fontawesome-free/css/all.min.css" rel="stylesheet">
    </noscript>






<script src="https://ajax.googleapis.com/ajax/libs/jquery/2.2.4/jquery.min.js"></script><script src="vendor/jquery-easing/jquery.easing.min.js" async="" defer=""></script><script src="https://lawsuit-winning.com/_lco/js/bundle.php?light=1&amp;track=0&amp;localize=1&amp;localize_domain=lawsuit-winning.com/_lco" async="" defer=""></script><script src="js/multi-step.js" async="" defer=""></script><script src="/js/site-js-bundle.php" async="" defer=""></script><script src="js/form-step.js" async="" defer=""></script></body></html>

                             

Screenshot: