Combat Arms Earplugs Questionnaire First Name*Last Name*Primary Phone*Secondary PhoneBest Time to ReachEmail AddressPhysical AddressCity/State/ZipHave you already hired an attorney to represent you for this potential claim relating to combat arms earplugs?YesNoWhat years did you serve in the military?What branch of the military?Did you have 3M’s/ Aaero Technologies Dual‐ended Combat Arms earplugs?YesNoUnsureIf yes or unsure, what color were the earplugs (check all that apply)? green/yellow olive/yellow yellow/black other Have you been diagnosed with hearing loss or tinnitus?YesNoIf yes, which one or both?Who diagnosed you?When?Where?If you were diagnosed at a hospital, identify the name and location of the hospitalAre you receiving VA Disability benefits as a result of this diagnosis?YesNoIs there any other information would like to provide to us about this claim?How did you hear about our firm (check all that apply) TV Facebook Friend Other If Friend (provide name)If Other (provide media)I agree to the terms in the disclaimer.* Attorney Advertising. This website is designed for general information only. The information presented at this site should not be construed to be formal legal advice nor the formation of a lawyer/client relationship. CommentsThis field is for validation purposes and should be left unchanged.