Join the Fight Please fill out the form below as completely as possible to have your potential claim evaluated. Name * First Name Last Name Email * Phone * (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Are you a Veteran or a family member of an injured Veteran? * If you are not the injured, please provide your name and relationship to the injured. Attack Date Causing Physical Injury * Attack City / FOB * Attack Province * Attack Type * EFP IED Rocket Mortar Suicide Bomb RPG Small Arms Other Does the attack match one of the following location and date ranges? * Army Canal - Baghdad - 2007-2008 Baqubah - 2005-2011 Basra - 2006-2011 Camp Victory - Baghdad - 2007 Diwaniya - FOB - Diwaniya - 2007 Doura (dora) - South Baghdad - 2006-2009 Fallujah - 2004-2007 FOB Loyalty - Baghdad - 2006-2008 Hadithah - 2004-2007Hit - 2004-2007 Kadhimiya - Shaab - North West Baghdad - 2007-2008 Mosul - 2003-2011 Ramadi - 2004-2007 Rustumiya - Camp Rustumiya - Central Baghdad - 2007-2008 Sadr City - 2004-2011 Taji - North of Baghdad - 2007 OTHER Attack Details (Including dates of additional attacks) * Do you have reports and/or Awards/Medals that reference the attack? * If yes, please provide the name of the report or note any explanation for no. * Do you have any photos/videos showing the attack or aftermath? * If yes, please provide the details. Are you aware of any other person(s) injured as a result of the attack? If so, please provide names. Are you aware of any person(s) who was killed during this attack? If so, please provide the names: Are you aware of any other witnesses to this attack? If so, please provide the names Please provide your injury details. * Did you receive a Purple Heart as a result of the attack? * Yes No Thank you for submitting! Someone from our team will get back with you shortly.
