Asbestos register form

1 Email address

2 & 3 First and last name

4 Postal address

5 Post code

6 Home telephone number

7 Are you a current member of BECTU?
Yes No

8 If yes BECTU membership number

9 Have you been exposed to asbestos?
Yes No

10 If yes provide details of where and when you were exposed to asbestos

10.11 Name of first employer and address of premises where you were exposed

10.12 Name of Branch

10.13 Start date of employment

10.14 End date of employment

10.15 Brief description of how you were exposed to asbestos

10.16 Names and, if possible, addresses of any workmates or witnesses who can confirm how you were exposed to asbestos.

10.21 Name of second employer and address of premises where you were exposed

10.22 Name of Branch

10.23 Start date of employment

10.24 End date of employment

10.25 Brief description of how you were exposed to asbestos

10.26 Names and, if possible, addresses of any workmates or witnesses who can confirm how you were exposed to asbestos.

10.31 Name of third employer and address of premises where you were exposed

10.32 Name of Branch

10.33 Start date of employment

10.34 End date of employment

10.35 Brief description of how you were exposed to asbestos

10.36 Names and, if possible, addresses of any workmates or witnesses who can confirm how you were exposed to asbestos.

10.41 Name of fourth employer and address of premises where you were exposed

10.42 Name of Branch

10.43 Start date of employment

10.44 End date of employment

10.45 Brief description of how you were exposed to asbestos

10.46 Names and, if possible, addresses of any workmates or witnesses who can confirm how you were exposed to asbestos.

11 Any additional information relating to section 10

12 Have you ever been told that you may be suffering from any asbestos related disease?
Yes No

13 If yes, have you been told which of the following you are suffering from?
Mesothelioma
Pleural Plaques
Pleural Thickening
Asbestosis
Lung Cancer

14 When were you diagnosed?

15 Have you ever applied to the DSS for benefit for asbestos related disease?
Yes No

16 If yes, when did you claim?

17 Have you ever previously obtained legal advice in connection with your asbestos exposure?
Yes No

18 If yes, name and address of the solicitors.

By selecting submit below I confirm that I consent to this information being stored on a database and shared with others, including other law firms instructed by the Union and it belongs to BECTU for the benefit of the members. The use of this data will be solely for the purpose of assisting personal injury claims on behalf of you or others who have been exposed to asbestos.

I also confirm that the contents of this statement are true.