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We understand that coming forward can be difficult for many reasons. If you have questions or want to discuss a potential case, please complete this form or call 1.888.425.2020.

1 Contact Information Tell us about yourself.
2 Case Details What should we know about your case?
3 Completion Thank you for reaching out!

Full Name

Phone

Litigation Area

Case

State/Province

Have you or a loved one developed a brain disorder, such as encephalitis or meningoencephalitis, after taking Zinbryta?

Yes

Did you take Zantac and/or a generic version?

Yes, prescription Zantac only

Yes, over-the-counter Zantac only

Yes, generic only

Yes, a mix of both

I'm not sure

Have you been diagnosed with any of the following after taking Zantac?

Stomach cancer

Bladder cancer

Pancreatic cancer

Liver cancer

Esophageal cancer

Other injury, explain below

No injury

Did you or a loved one consume recalled WanaBana Apple Cinnamon Pouches?

Yes

Have you or a loved been diagnosed with lead poisoning after consuming the product?

Yes

Have you experienced serious health issues associated with transvaginal mesh?

Yes

Have you had one or more revision surgeries as a result of mesh?

Yes

What state did your accident occur in?

When did your accident occur?

Have you or a loved one been diagnosed with a debilitating injury after taking PPIs?

Acute interstitial nephritis

Chronic kidney disease

Kidney failure

Other, explain below

No diagnosis

Were you exposed to per- and polyfluoroalkyl substances (PFAS) "forever chemicals," either through aqueous film-forming foam (AFFF) or another source? Choose all applicable.

Yes, exposed as a fire fighter to foam

Yes, exposed as a fire fighter to bunker gear

Yes, exposed through water consumption

Yes, exposed through another source. Explain below

Were you diagnosed with any of the following conditions after exposure?

Kidney cancer

Liver cancer

Testicular cancer

Thyroid Cancer

Thyroid disease

Ulcerative colitis

Other…

Year of diagnosis:

Do you rent/own property or a business that was impacted by the Norfolk Southern train derailment?

Yes

Type of property

Do you own any livestock that have incurred medical expense or have passed away as a result of Norfolk Southern train derailment?

Yes

Are you experiencing any new medical conditions or injuries since the train derailed?

Yes

Type of injury

Were you implanted with a metal-on-metal hip replacement device?

Yes

What type of insulin pump do you use?

600 Series Medtronic MiniMed Insulin Pump - Model 670 G

600 Series Medtronic MiniMed Insulin Pump - Model 640 G

600 Series Medtronic MiniMed Insulin Pump - Model 630 G

600 Series Medtronic MiniMed Insulin Pump - Model 620 G

I'm not sure

Other, explain below

We are not interested in non-U.S. claims.

Have you experienced any of the following side effects?

Brain injury

Coma

Seizure

Loss of consciousness

Death

Other injury, explain below

No injury

Have you had a retrievable IVC filter surgically implanted after Jan. 1, 2003?

Yes

Have you experienced any side effects? Select all that apply

Additional surgeries

Detached device components

Device fracture

Device migration/tilting

Vein or organ perforation

Irretrievable device

Other, explain below

Have you or a loved one been victim to human trafficking?

Yes

What state did the trafficking take place?

When did the trafficking take place?

How old were the people being trafficked?

What business or entity facilitated the trafficking?

Were you or a loved one harmed by Hamas?

Yes

Only certain people are allowed to bring a claim using these laws. Are you a:

U.S. National

The family member of a U.S. National

U.S. Servicemember

U.S. Government Contractor

Make and Model

Dodge Charger

Chrysler 300

Jeep Grand Cherokee

Maserati Quattraporte or Ghibli

Model Year

When did your accident occur?

What state did your accident occur in?

Do you believe your insurance company has charged you more than the actual cost of medical services or products?

Yes

Do you suffer from shortness of breath, a chronic cough, or wheezing

Yes

Have you been diagnosed with lung disease

Yes

Have you been exposed to chemical flavoring from food products or from e-cigarettes

Yes

Have you been burned or injured by a defective device?

Yes

Were you implanted with a Exactech hip, knee or ankle replacement?

Yes

Did you take Elmiron?

Yes

I'm not sure

Have you experienced any of the following side effects after taking Elmiron?

Have you had an endoscopy between Jan. 1, 2010 and Oct. 31, 2015?

Yes

Were you injured by an EFP in Iraq between the Fall of 2005 and December 2012?

Yes

Do you use a Dexcom G6 and Dexcom App?

Yes

Have you experienced any of the following side effects?

Brain injury

Coma

Seizure

Loss of consciousness

Death

Other injury, explain below

Have you or a loved one been injured in an accident where your vehicle failed to perform as the manufacturer intended?

Yes

When did the accident occur?

What state did your accident occur in?

Have you been diagnosed with Parkinson’s Disease?

Yes

How were you exposed to paraquat?

I was a licensed applicator

I worked for a licensed applicator

Other, explain below

Have you or a loved one been victim to childhood sexual abuse?

Yes

What state did the acts take place?

When did the acts take place?

How old were the people being abused?

What group or institution facilitated the acts?

Have you been exposed to hair relaxer products and diagnosed with uterine, ovarian or endometrial cancer?

Yes

Were you injured on a plane or in an airport or other transportation facility?

Yes

Did your injuries require significant medical treatment or hospitalization?

Yes

Were you arrested and jailed in an airport or other transportation facility?

Yes

Were you released without charges, prosecution, guilty pleas, or convictions of charges?

Yes

Have you been exposed to Roundup products and developed non-Hodgkin lymphoma?

Yes

What time period were you at Camp Lejeune?

In what capacity were you at Camp Lejeune?

Served with U.S. Armed Forces

Service member spouse or family member

Government contractor

Other…

Were you exposed to per- and polyfluoroalkyl substances (PFAS) "forever chemicals," either through aqueous film-forming foam (AFFF) or another source? Choose all applicable.

Yes, exposed as a fire fighter to foam

Yes, exposed as a fire fighter to bunker gear

Yes, exposed through water consumption

Yes, exposed through another source. Explain below

Were you diagnosed with any of the following conditions after exposure?

Kidney cancer

Liver cancer

Testicular cancer

Thyroid Cancer

Thyroid disease

Ulcerative colitis

Other…

Year of diagnosis:

Did you use artificial tears and subsequently suffered from vision loss?

Yes

Which artificial tear product(s) did you use?

EzriCare® Artificial Tears

Delsam Pharma® Artificial Tears Lubricant Eye Drops

Other

What state did your accident occur in?

When did your accident occur?

Do you own 2011-2015 model Audi or Volkswagen with a 3.0 Liter TFSI engine?

Yes

Model Year

Vehicle Identification Number

Did your child develop NEC after consuming cow milk-based formulas?

Yes

Did your baby develop complications after consuming a recalled product made by Abbott Nutrition?

Yes

Do you have evidence your child consumed a recalled formula?

Yes

Did you take Belviq and/or a generic version?

Yes, Belviq only

Yes, generic only

Yes, a mix of both

I'm not sure

Have you been diagnosed with any of the following after taking Belviq?

Pancreatic cancer

Colorectal cancer

Lung cancer

Other injury, explain below

No injury

Medical Device

Medical Drug

Did your loved one consume baby food on a regular basis from one of the following manufacturers:

Happy Family Organics (HappyBABY);

Beech-Nut

Hain Celestial Group (Earth’s Best Organic

Gerber

Campbell (Plum Organics)

Wal-Mart (Parent’s Choice/Parent’s Choice Organics); or Sprout Organic Foods

Do you still have any of these products?

Yes

Has your loved one been diagnosed by a medical professional with

Autism Spectrum Disorder (ASD)

Attention Deficit Disorder (ADD)

Attention-Deficit/Hyperactivity Disorder (ADHD)

Was that diagnosis before the age of 14 years old?

Yes

Did you have a breast implant procedure?

Yes

Have you been diagnosed with breast implant-associated anaplastic large cell lymphoma (BIA-ALCL)?

Yes

Did you use talcum powder?

Yes

Have you been diagnosed with ovarian cancer after talcum powder use?

Yes, ovarian cancer

No, other injury

No, no injury

Have you been hospitalized or required medical care for any of the following conditions?

Diabetes

Intestinal obstruction

severe or permanent stomach paralysis

gastric distress

pancreatitis

pancreatic cancer

surgical complications

Did you use a telehealth provider to get your prescription?

Yes

Have you or a loved one had a hernia surgically repaired using mesh?

Yes

Did you have problems following the initial hernia surgery?

Regular pain or discomfort

Device migration

Bacterial infections

Additional surgeries

Other, please explain...

Was the initial hernia surgery after January 1, 2000?

Yes

Have you had a hernia revision surgery because of faulty hernia mesh, not hernia reoccurrence?

Yes

Medical Drug

Have you been implanted with a Paragard IUD?

Yes, just one

Yes, multiple implants

Have you experienced any side effects? Select all that apply

IUD BREAKAGE UPON REMOVAL

SURGERIES, INCLUDING HYSTERECTOMY

INFERTILITY

DEATH

Have you had a hysterectomy or another surgery to remove this device?

Yes

Did you use Depo-Provera or a related product?

Yes, Depo-Provera

Yes, Depo-SubQ Provera

Yes, an authorized generic medroxyprogesterone acetate birth control shot

Did you develop meningioma after?

Yes

Did you lose an embryo during an IVF procedure that used CooperSurgical IVF fluid?

Yes

Is your vehicle equipped with Onstar?

Yes, I pay the subscription

Yes, someone else pays the subscription

No, I do not subscribe to OnStar services

Did you download your vehicles MyCAR app (MyBuick, MyGMC, MyCadillac, or MyChevrolet)?

Yes

Did your insurance change after enabling OnStar's Smart Driver Program?

Insurance rates increased

Insurance policy cancelled

Other issues, explain below

Have you or a loved one experienced a serious injury that resulted in medical expenses, loss of income, long-term care or rehabilitation?

Yes

Have you been diagnosed with an injury following exposure to a contamination of your home, health or the environment?

Yes

Were you or a loved one pregnant while living near or working on a farm that applied DCPA?

Yes

Did the child from that pregnancy suffer from any birth issues, neurological deficits or low birth weight?

Yes

Have you or a loved been diagnosed with lead poisoning after exposure to lead?

Yes

What type of fraud?

CFTC

IRS

SEC

Qui Tam

Other…

Have you or a loved one been victim to human trafficking?

Yes

I have other information

Where did the trafficking take place?

When did the trafficking take place?

How old were the people being trafficked?

What business or entity facilitated the trafficking?

Which Sony PlayStation consoles did you purchase?

PlayStation 4

PlayStation 5 (disc)

PlayStation 5 Digital Edition

Where did you purchase digital games?

I only purchased digital games from the PlayStation Store

I only purchased digital games from other retailers

I purchased digital games from both the PlayStation Store and other retailers

Do you have receipts for your PlayStation digital game purchases from a retailer?

Yes

Medical Drug

Provide some information about your potential case

By submitting this form, I agree that Motley Rice LLC may collect my information and use it pursuant to its privacy policy.

I agree

Yes

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FAQs & Additional Resources

Will I have to put up any money to get started?

Our initial consultation is always free. Most cases use a contingent fee contract, meaning we don't get paid until or unless our clients make a recovery. This contingent fee will be a percent of the recovery, calculated before deducting expenses. In some circumstances, a retainer agreement may include representation on an hourly basis. However, we recommend speaking with an attorney to learn more.

What do you need to know about my potential case?

When someone from our law firm speaks with you, we'll need to gather some basic information about your case. This can include names and dates, as well as a timeline relating to the claim. The more information you can provide, the better.

Where does Motley Rice handle cases?

Motley Rice represents clients across the globe. We litigate cases in all 50 states, as well as internationally. We are comfortable working along with co-counsel if needed.

What can I do if I'm not sure that I'm completing the right form?

We understand that it may feel overwhelming trying to get all of the details right. If you're unsure that you're completing the right form, please call [NUMBER]. Our staff can work with you to understand your claim and do what we can to help.

Additional Resources